HX641 20635 
 RC71.B791914 Diagnostic methods, 
 
 RECAP 
 
V 
 
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 in tfje Citp of j^eto gorfe 
 
 College of ^fjpsictanfi anb burgeons 
 
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DIAGNOSTIC METHODS 
 
DIAGNOSTIC METHODS 
 
 A Guide for History Taking, Making of Routine 
 
 Physical Examinations and the Usual 
 
 Laboratory Tests Necessary for 
 
 Students in Clinical Pathology, 
 
 Hospital Internes, and 
 
 Practicing Physicians 
 
 By 
 HERBERT THOMAS BROOKS, A.B., M.D., 
 
 Professor of Pathology, University of Tennessee, College of Medicine, 
 Memphis, Tennessee 
 
 SECOND EDITION 
 
 Revised and Revjritten 
 
 ST. LOUIS 
 C. V. MOSBY company 
 
 1914 
 
Copyright, 1914, By C. V. Mosby Company 
 
 Press of 
 
 C. V. Mosby Company 
 
 St. Louis 
 
PREFACE TO SECOND EDITION 
 
 This little book is intended for medical students, hospital 
 internes and physicians who have a limited amount of time 
 to give to laboratory work. 
 
 Every possible care has been used to incorporate in this 
 guide only the up-to-date and absolutely reliable laboratory 
 tests. If one is able to perform these tests accurately and at 
 the same time place the proper interpretation on the results, 
 he will be very materially assisted in coming to an accurate 
 diagnosis. 
 
 H. T. B. 
 
 Memphis, Tenn., 
 January, 1914. 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/diagnosticmethodOObroo 
 
CONTENTS 
 
 Chapter I. Pages 
 
 Outline for History Taking 9-12 
 
 Chapter II. 
 Pliysical Examination of the Patient 13-18 
 
 Chapter III. 
 Sputum 19-24 
 
 Chapter IV. 
 Urine , 25-37 
 
 Chapter V. 
 Gastric Contents 38-44 
 
 Chapter VI. 
 Blood - 45-53 
 
 Chapter VII. 
 Serous Fluids 54-57 
 
 Chapter VIII. 
 Intestinal Contents 58-63 
 
 Chapter IX. 
 Tuberculin Diagnosis 64-66 
 
 Chapter X. 
 The Wassermann Reaction 67-71 
 
 Chapter XI. 
 Complement Fixation Test for Gonorrhea 72-73 
 
 Chapter XII. 
 
 Apparatus and Chemical Reagents Necessary for a Physician's 
 
 Laboratory 74-76 
 
DIAGNOSTIC METHODS 
 
 CHAPTEE I. 
 OUTLINE FOR HISTORY TAKING. 
 
 Obtain from the patient the following : 
 
 1. Name. 5. Address, 
 
 2. Age. 6. Weight. 
 
 3. Occupation. 7. Height. 
 
 4. Social Relation. 8. Color. 
 
 Chief Complaint and Duration of Symptoms. 
 
 Secure from patient in as few words as possible the thing 
 or things that give him the most trouble. Get date of begin- 
 ning and duration of each. 
 
 Family History. 
 
 If living, the health of, or if dead the cause and age of 
 death of father, mother, brothers, sisters, uncles and aunts. 
 Secure positive or negative history of tuberculosis, cancer, 
 rheumatism, gout, diabetes. 
 
 Personal History. 
 
 Get the habits of the patient as to the use of alcohol, to- 
 bacco and drugs ; habits as to sleep ; exact nature of past and 
 present occupations ; condition of present surroundings, 
 
 (9) 
 
10 Diagnostic MetJiods. 
 
 whether sanitary or not. If the patient is a woman obtain 
 the following: 
 
 Menstrual History. — Age of commencement; regularity; 
 duration; quantity, whether copious or scanty, associated 
 with pain ( ? ) ; date of last menstruation ; presence of leucor- 
 rhea. 
 
 Obstetrical History. — ^Number of children, age of 
 youngest, number of miscarriages, date of last, character of 
 labor, complications occurring during labor or immediately 
 following. 
 
 Past History. 
 
 Diseases of childhood, especially acute rheumatism, scar- 
 latina, diphtheria, or tonsillitis. All other diseases or inju- 
 ries prior to this illness. Ask your patient if he has had syph- 
 ilis, or if he has been exposed to same. Also ask if he has had 
 gonorrhea or a sore of any kind. Any acute infection as 
 typhoid or pneumonia? 
 
 History of the Present Illness. 
 
 Chief complaint, date of beginning ; onset, slow or sudden ; 
 order of appearance of symptoms, which gave patient the 
 most trouble ; character of treatment if any. ' 
 
 Alimentary Canal. — 
 
 If symptoms indicate disease of the alimentary canal, ask 
 the following questions: (a) Appetite; (b) Meals — nature 
 of the food patient most craves; (e) Sensations referred to 
 the stomach — pain, fullness, or discomfort. Give location of 
 pain and radiation if any; (d) Vomiting — time of day, rela- 
 tion to food, relieves pain or not, any retching; (e) Charac- 
 ter of vomited material — amount, color, red, coffee grounds, 
 sour or frothy ; (f) Eructations of gas ; (g) Flatulence — rela- 
 tion to what particular kind of food, and does the gas tend 
 to go up or down; (h) State of, the bowels — as the presence 
 of diarrhoea — is it associated with blood, slime or tenesmus, 
 does any particular kind of food appear to bring it on? (i) 
 Constipation — usual habits as to bowel movement; (j) Pain 
 in the abdomen — where is it the worst, is it persistent or 
 
Outline for History Taking. 11 
 
 intermittent, is it relieved or made worse by pressure? Is 
 there any radiation, any soreness following? 
 
 Liver. — 
 
 If symptoms indicate the trouble to be in the liver, the fol- 
 lowing questions are to be asked: (a) Pain — any severe 
 pain coming on and lasting a few hours only. Was the pain 
 associated with vomiting? Does it radiate? Any pain in the 
 shoulder? Was the patient yellow after the attack? (b) 
 Piles; (c) Vomiting of blood; (d) Any change in the color 
 of urine or feces; (e) Inquire as to the presence of digestive 
 disturbances. 
 
 Cardiovascular System. — 
 
 If the symptoms indicate that the trouble is in the cardio- 
 vascular system, the following questions should be asked: (a) 
 Any dyspnoea; (b) Precordial pain or discomfort — does it 
 radiate; (c) Any palpitation — relation to meals and exer- 
 tion? (d) Headache; (e) Giddiness; (f) Sleep; (g) Any 
 cough; (h) Presence of digestive disturbances; (i) Swelling 
 of feet; (j) Presence of nose bleeding? 
 
 Respiratory System. — 
 
 If the symptoms indicate that the trouble is in the respira- 
 tory system, the following questions should be asked: (a) 
 Any cough — character of cough, when worse, any pain, as- 
 sociated with vomiting; (b) Expectoration — ^yellow or not, 
 any blood present and how much, and whether only after 
 severe coughing; (c) Any pain in chest — pain on deep breath- 
 ing and where situated; (d) Dyspnoea — is it spasmodic, and 
 describe the attack if it is; (e) Night sweats; (f) Loss of 
 weight; (g) Loss of strength; (h) Fever; (i) Hoarseness. 
 
 Kidneys. — 
 
 If the symptoms indicate that the trouble is in the kidneys, 
 the following questions should be asked: (a) Any headache; 
 (b) Drowsiness; (c) Dimness of vision; (d) Attacks of 
 dyspnoea; (e) Vomiting; (f) Paralysis; (g) Convulsions; 
 (h) Does the face look puffy in the morning; (i) Any swell- 
 ing in the ankles; (j) Urine — altered in amount, clear or 
 
12 Diagnostic Methods. 
 
 turbid, any blood, and is it present at the early or the latter 
 part of urination; (k) Does the patient have to rise in the 
 night to pass urine; (1) Is there any increase in frequency 
 and is this by day or by night; (m) Pain on micturition? 
 (n) Pain in lumbar region — does it radiate to the groin. 
 
 Nervous System. — 
 
 If the symptoms indicate that the trouble is in the nervous 
 system, the following questions may be asked: (a) Any 
 headache (when worse, where located, character of the head- 
 ache) ; (b) Nausea or vomiting ; (c) Dizziness; (d) Difficulty 
 in walking; (e) Any transient palsies, or transient loss of 
 memory; (f) Any visual disturbances ; (g) Convulsions (gen- 
 eral or local, age of beginning, frequency, any premonition, 
 bite tongue, micturate or defecate) ; (h) Any discharge from 
 ear at any time. 
 
 Blood.— 
 
 If the symptoms indicate that the trouble is in the blood, 
 the following questions should be asked: (a) Any dyspnoea? 
 (b) Headache; (c) Dizziness; (d) Swelling of feet; (e) Pre- 
 vious attacks. 
 
 Bones and Joints. — 
 
 If the symptoms indicate that the trouble is in the bones 
 or the joints, the following questions may be asked : (a) Pain 
 in bone — worse day or night; (b) Pain in joint — constantly 
 present or only when the joint is moved; (c) Any sudden 
 starting pains at night; (e) Is the pain affected by the 
 weather; (f) Does the pain shift from one joint to the other. 
 
 Child.— 
 
 If the patient is a child, the following questions should be 
 put to the mother: (a) Number of children; (b) Any dead 
 and the cause; (c) Any miscarriages; (d) Mother's health 
 during pregnancy; (e) Is it a full time child; (f) Was the 
 labor normal; (g) Was the child breast fed; (h) What food 
 is being given the child at the present time; (i) Was there 
 any rash or snuffles after birth; (j) State the age of cutting 
 of teeth and walking; (k) Give the usual condition of the 
 child's bowels; (1) Any bronchitis, measles, whooping cough, 
 chicken pox, scarlatina, discharge from the ears. 
 
CHAPTER II. 
 PHYSICAL EXAMINATION OF THE PATIENT. 
 
 General Survey of the Patient. 
 
 Note the following: (a) Nutrition; (b) Attitude; charac- 
 teristic of any trouble; (c) Expression, whether animated, 
 apathetic or placid; (d) Complexion; (e) Eruptions; (f) 
 Enlargement of lymph nodes or presence of any tumor 
 masses; (g) Deformities, either congenital or acquired. 
 
 Examination of the Alimentary Canal and the Abdomen. 
 
 Examine. — 
 
 (a) Lips.' — ^Noting the presence of cyanosis, anaemia, 
 herpes, or fissures; (b) Teeth. — Note the presence of caries, 
 exposures of roots, pyorrhea, or congenital syphilis; (c) 
 ToisTGUE. — Note the presence of tremor, any deviation on pro- 
 trusion, size, papillse, coating (moist or dry) ; (d) Palate, 
 Fauces, and Pharynx. — Note the presence of ulcers, mucous 
 patches, enlarged tonsils, white patches on tonsils or uvula 
 or soft palate; (e) Esophagus. — ^Any difficulty in swallow- 
 ing, if necessary pass the stomach tube, and note presence of 
 pain, stricture or diverticulum ; (f) Abdomen.— Inspection. — 
 Note general contour, the presence of pulsations in epigas- 
 trium, movements of abdominal wall, peristaltic waves, pres- 
 ence of stride, pigmentations, or scars; Palpatio^i. — Examine 
 for the presence of tenderness, tumor, rigidity of muscles, 
 and gurgling; Percussion. — ^Examine for dullness in the 
 flanks, if present is it movable, presence of free gas in the 
 peritoneal cavity; (g) Stomach. — Inspection. — Examine for 
 the presence of visible tumors, dilatations, and peristaltic 
 waves; Palpation. — Examine for tenderness, tumors, and 
 splashing; Percussion. — Examine for position of greater 
 curvature, lower border of liver and lung. Inflate the stom- 
 ach and examine for size and position. 
 
 (13) 
 
14 Diagnosiic Methods. 
 
 Liver. — Inspection. — Look for the edge of the liver and 
 the presence of pulsations. Palpation. — Examine for tender- 
 ness, position of the lovrer border, regularity or irregularity 
 of surface. Percussion. — Examine for upper border of dull- 
 ness in the mid-clavicular line, mid-axillary line and scapula 
 line. 
 
 Spleen. — Note whether or not palpable, position of the 
 lower pole. 
 
 Kidneys. — Note whether or not palpable, presence of ten- 
 derness, and extent of mobility. 
 
 Examination of the Cardiovascular System. 
 
 Heart. — Inspection.' — Note the shape of the praecordial re- 
 gion, presence of pulsation — normal and abnormal in the 
 precordial region and immediately beyond, as in episternal 
 notch, neck, to right of sternum, and epigastrium. 
 
 Palpation. — ^Location and description of apex beat, pres- 
 ence and location of thrills, and whether systolic, diastolic, 
 or presystolic. Note the presence of a friction rub, and any 
 abnormal pulsations. 
 
 Percussion. — Outline of superficial and deep cardiac dull- 
 ness; description of any abnormal areas of dullness. 
 
 Auscultation. — Relative intensity of heart sounds in va- 
 rious valvular areas. Note the presence and give description 
 of adventitious sounds, as cardiac murmurs, vascular mur- 
 murs, and pericardial friction rub. 
 
 Pulse. — Note the presence of arteriosclerosis; approxi- 
 mate blood pressure, whether low, moderate or high; char- 
 acter and quality of the pulse, especially whether character- 
 istic of aortic insufficiency or stenosis. Note the presence or 
 absence of venous pulsation in the neck. 
 
 Examination of the Respiratory System. 
 
 Thorax. — Inspection. — Note the shape whether symmet- 
 rical or the presence of unilateral depressions or fullness. 
 Note the presence of alar chest, flat chest, emphysematous 
 
Physical Examination of the Patient. 15 
 
 chest, rachitic rosary, pigeon breast, Harrison's sulcus. 
 Note intercostal spaces for undue fullness or retraction. Note 
 the respiratory movements as to rate, type, equality or in- 
 equality of expansion. Note the presence of Litten's dia- 
 phragmatic sign. 
 
 Palpation. — Examine the respiratory movements as to 
 equality or inequality of expansion. Note any localized de- 
 ficiency of expansion. Note the presence and location of 
 friction fremitus. Examine the vocal fremitus as compared 
 with the normal. 
 
 Percussion. — Compare the corresponding areas of the 
 chest. Outline the apices, lower borders of both lungs, and 
 note whether the resonance is normal, diminished, or in- 
 creased. Note the presence and location of any abnormal 
 areas of dullness. 
 
 Auscultation. — Note the character of the breath sounds, 
 whether normal, increased, diminished or absent. Note the 
 presence and location of any abnormal areas of tubular, 
 broncho-vesicular, cogwheel, or other abnormal types of 
 breathing. Note the presence of any adventitious sounds, as 
 rales (dry, bubbling, crepitant, or sub-crepitant). Also note 
 pleuritic friction sounds. Note vocal resonance, whether 
 normal, increased, diminished or absent. 
 
 Examination of the Nervous System. 
 
 Cranial Nerves. — 
 
 Olfactory Nerves. — Use oil of cloves, oil of peppermint 
 or asafoetida. Compare the sense of smell in both nerves. 
 
 Optic Nerves. — Test the acuteness of vision, extent of 
 visual fields in both eyes. 
 
 Motor Oculi, Troclear, and Abducent Nerves. — Note 
 the presence of strabismus, or ptosis. Test for defects in 
 ocular movements, for diplopia, and for nystagmus. Note 
 the size and shape of pupils. Test their reaction to light 
 and accommodation. 
 
 Trifacial Nerves. — Test the motor functions by having 
 the patient clinch the teeth tightly, and feel the contractions 
 
16 Diagnostic Methods. 
 
 of masseter and temporal muscles. Test the sensory func- 
 tions. 
 
 Facial Nerves. — Close the eyes tightly, wrinkle the fore- 
 head, and elevate the upper lip, noting any lack of symmet- 
 rical muscular action. 
 
 Auditory Nerves. — Test acuteness of hearing on both 
 sides with watch. Examine for the presence of vertigo. 
 
 Glossopharyngeal Nerves. — Examine for taste on the 
 posterior surface of the tongue by using a little sugar or 
 quinine. Tickle the pharynx and note the presence of any 
 gagging. 
 
 Vagus Nerves. — Have patient to swallow liquid and note 
 any regurgitation through the nose. Ask the patient to say 
 "ah," and note if both the sides of the palate are raised 
 equally. 
 
 Spinal Accessory Nerves. — Have the patient to shrug 
 the shoulders, also to rotate the chin from side to side, noting 
 any difference in the movements. 
 
 Hypoglossal Nerves. — Protrude the tongue, and note the 
 presence of any deviation, or any atrophy. 
 
 Motor Functions. — 
 
 Compare strength of corresponding groups of muscles in 
 the upper and the lower extremities. Examine for muscular 
 incordination in the upper and lower extremities. Note state 
 of nutrition of the muscles, and presence of any atrophy. 
 Examine for abnormal muscular movements such as tonic 
 spasms, clonic spasms, contractures, tetany, convulsions, in- 
 tention tremor, fibrillary twitchings, choreic movements, 
 athetosis. Examine for any muscular rigidity or flaccidity. 
 Test for the presence of Kernig's sign. 
 
 Sensory Functions. — 
 
 Test for common sensibility with feather or cotton. Note 
 the presence of areas of anesthesia or hyperesthesia. Test 
 for sense of pain. Use pin point and note the presence of 
 areas of analgesia, hyperalgesia, or delayed conduction. Test 
 for temperature sense, using test tubes with warm and cool 
 water. Test for muscular sense, both as to sense of weight 
 
Physical Examination of the Patient. 17 
 
 and position. Inquire as to any abnormal sensations, such as 
 girdle pain, formications, pins and needles sensations, or 
 numbness. 
 
 Reflexes. — 
 
 Superficial Reflexes. — Test for: (a) Plantar reflex, 
 (Babinski's sign is an extensor plantar reflex occurring 
 chiefly in pyramidal tract lesions), (b) Conjunctival reflex; 
 (c) Pupil reflex; (d) Palate reflex; (e) Cremasteric reflex; 
 (f) Abdominal reflex; (g) Epigastric reflex. 
 
 Deep Reflexes. — Test for: (a) Knee jerk; (b) Ankle 
 jerk; (c) Elbow jerk; (d) Jaw jerk; (e) Ankle clonus; (f) 
 Patella clonus. 
 
 Organic Reflexes. — Inquire as to: (a) Deglutition; (b) 
 DefiPcation; (c) Micturition; (d) Incontinence, hesitancy or 
 retention of urine. 
 
 Examination of the Locomotor System. 
 
 Examine shafts of bones for signs of former fractures, 
 thickening of periosteum, or the presence of tenderness. Ex- 
 amine the ends of the bones for enlargement as in rickets or 
 nodules as in rheumatoid arthritis. Examine joints for the 
 presence of swelling, tenderness, fluctuation, or redness. Ob- 
 serve the degree of motility in every direction. Examine the 
 vertebral column for the presence of tenderness, local projec- 
 tions, lordosis, kyphosis, scoliosis, and mobility of the vertebra. 
 
 EX.VMINATION OF THE Gait. — (a) Spastic gait, as occurs in 
 hemiplegia; (b) Ataxia gait, as occurs in tabes; (c) Reeling 
 gait, as in a drunkard; (d) Festinant gait, as in paralysis 
 agitans; (e) Waddling gait, as in pseudohypertrophic mus- 
 cular paralysis; (f) High stepping gait, as in multiple per- 
 ipheral neuritis. 
 
 Romberg's Sign. — Test for its presence. 
 
 Examination of Eyes, Ears, Nose, and Larynx. 
 Eyes. — 
 
 (a) Pupils (size, equality, shape, reflexes, Argyll Robert- 
 son) ; (b) Strabismus; (c) Ptosis; (d) Nystagmus (lateral 
 
18 .Diagnostic Methods. 
 
 or vertical); (e) Conjunctivitis; (f) Exophthalmos; (g) 
 Vision (hemianopsia, condition of retina) ; (h) Oedema of 
 lids. 
 
 Ears. — 
 
 (a) Hearing; (b) Discharge; (c) Examination of canal 
 for foreign bodies, or wax; (d) Examine tympanum; (e) 
 Note any tenderness over mastoid. 
 
 Nose. — 
 
 (a) Discharges; (b) Deformities; (c) Tumors; (d) Epis- 
 taxis; (e) Deviations of septum; (f) Presence of spurs; (g) 
 Enlarged turbinates. 
 
 Larynx. — 
 
 If there are any voice changes, a laryngoscopic examina- 
 tion is indicated. 
 
CHAPTER III. 
 SPUTUM. 
 
 Origin. — May be from mouth, nose, pharynx, larynx, 
 bronchi or lungs. One or more or all. Note whether hawked 
 up or coughed up. 
 
 Quantity. — The quantity varies within wide limits; as in 
 early tuberculosis it is small, but in chronic bronchitis or 
 bronchiectasis it is large. 
 
 Odor.— Ordinarily there is no odor to sputum. In case of 
 abscess or gangrene of the lung it may be very disagreeable. 
 
 Sputum for ExamiNx\tion should be coughed up and not 
 hawked. In case of children it may be necessary to insert a 
 swab in the pharjaix, and as a result of this irritation the 
 sputum will be coughed up and can be removed before it is 
 swallowed. 
 
 When a Specimen op Sputum Is Received, pour the 
 sputum in a petri dish and place on cover. Place the sputum 
 container in water and boil. Treat also in this manner the 
 petri dish and sputum after examination. 
 
 Macroscopic Examination of the Sputum. — 
 
 This shows the following : 
 
 1. Mucous or Viscid Sputum. — Seen in early stages of 
 bronchitis and pneumonia. 
 
 2. Mucopurulent Sputum. — This is the most common 
 form and is not characteristic of any particular condition. 
 
 3. Purulent Sputum. — This is seen in pure form only in 
 perforation into the lungs or bronchi of foci of pus, as in 
 abscess of lung or empyema. 
 
 4. Serous Sputum. — This is often slightly red in color 
 and frothy. The red color is due to blood. This sputum is 
 characteristic of pulmonary oedema. 
 
 (19) 
 
20 Diagnostic Methods. 
 
 5. Nummular Sputum. — Each part expectorated tends to 
 collect to itself. This is common in tuberculosis of the lungs. 
 
 6. Hemorrhagic Sputum.~T\ih is seen in phthisis, pneu- 
 monia, epistaxis, abscess of lung, hemorrhagic infarction, 
 new growths and passive congestion. 
 
 7. Tenacious Sputum. — Adheres to an inverted cup. This 
 is seen in pneumonia. 
 
 Note the Color of Sputum as follows : 
 
 1. Rusty or Orange Juice in color. This is common in 
 pneumonia. 
 
 2. Prune Juice in Appearance. Sometimes seen in pneu- 
 monia and often in cancer and gangrene of lungs. 
 
 3. Grass-Green. This is seen in pneumonia in combina- 
 tion with jaundice. 
 
 4. Black or Gray. This is due to substances inhaled, as 
 coal dust. The sputum may be gray or black from food, as 
 chocolate ; and also tobacco. 
 
 5. Reddish-Yellow. Seen when abscess of liver ruptures 
 into lung. 
 
 6. Hemorrhagic Sputum. Seen in pulmonary tuberculo- 
 sis, pulmonary infarcts, passive congestion of lungs, lobar 
 pneumonia, leaking aneurysm, and tuberculosis of lungs, etc. 
 
 Microscopic Examination Should be Made for the following : 
 
 1. Unimportant Constituents Often Seen. — (a) leuco- 
 cytes; (b) a few red blood cells; (c) epithelial cells, both 
 squamous and columnar in type; (d) "heart failure" cells, 
 pigmented epithelial cells from lining of the alveoli : results 
 from passive congestion of lungs; (e) various bacteria; (f) 
 particles of food. 
 
 2. Important Constituents to he Examined for: 
 
 (a) Bacteria: this includes, the tubercle bacillus, influ- 
 enza bacillus, pneumococcus, streptococcus, staphylococcus 
 and Friedlander's bacillus. 
 
 (b) Elastic Fibers; this is seen in all destructive proc- 
 esses of the lungs, as phthisis, gangrene and abscess. 
 
Sputum. 21 
 
 (c) Curschmann's Spirals and Charcot-Leyden Crystals. 
 
 For an examination, microscopically, of the sputum for 
 leucocytes, epithelial cells, influenza bacillus, Friedlander's 
 bacillus, streptococcus and staphylococcus the Loffler's methy- 
 lene-blue stain is sutflcient. 
 
 This is as follows: 
 
 1. Make cover glass preparation from a purulent particle 
 of the sputum and spread it thinly. Dry in air. 
 
 2. Fix by passing through flame three times. 
 
 3. Stain in Loffler's methylene-blue for 30 seconds, heat- 
 ing to the steaming point, or 1 to 2 minutes without heating. 
 
 4. Wash in water, dry, and mount in balsam. 
 
 Method of Staining Bacillus Tuberculosis in Sputum. — 
 
 1. Select a purulent or cheesy particle from the sputum 
 and smear it thinly on a slide and let it dry in the air. 
 
 2. Fix the specimen by passing through flame four or 
 five times. 
 
 3. Cover with carbol-fuchsin solution and steam from 
 two to three minutes over Bunsen burner or alcohol lamp. 
 Do not let the stain dry, but add more of the stain if neces- 
 sary. 
 
 4. Wash in water. 
 
 5. Decolorize in acid alcohol until a pinkish tinge remains. 
 
 6. Wash in water. 
 
 7. Cover the specimen with Loffler's methylene-blue solu- 
 tion for 30 seconds. 
 
 8. Wash in water, dry, mount in balsam and examine 
 with oil immersion lens. The tubercle bacilli are stained 
 bright red, nuclei and other bacteria are blue. 
 
 Method of Staining the Pneumococcus. — 
 
 The pneumococcus may be stained by the Loffler's methy- 
 lene-blue solution, but probably the most satisfactory method 
 is Gram's stain. 
 
22 Diagnostic Methods. 
 
 Reagents required for Gram's stain: 
 
 1. Anilene water, made by placing 3 to 5 c.c. of anilene 
 oil in test tube, and four times this quantity of tap water. 
 Shake wel], and filter through two sheets of filter paper. 
 
 2. Anilene water gentian violet, made by adding two or 
 three drops of saturated alcoholic solution of gentian violet 
 to the anilene water, and filter. 
 
 3. Gram's iodine solution. (See composition of reagents.) 
 
 4. Diluted carbol-fuchsin : Made by adding two (2) parts 
 of water to one part of carbol-fuchsin, then filter. 
 
 Following is the Method of Gram's Stain: 
 
 1. Cover the cover glass containing the smear with ani- 
 lene water gentian violet for 2 to 3 minutes; blot dry. 
 
 2. Gram's iodine for 1"^/^ minutes; blot dry. 
 
 3. 95 per cent alcohol ; pour on and off until all the blue 
 color comes away. 
 
 4. Wash in water. 
 
 5. Diluted carbol-fuchsin (1 to 2 with water) for one- 
 half to one minute. 
 
 Wash in water, mount and examine. The pneumococcus 
 and all Gram positive organisms are colored blue. All Gram 
 negative organisms are colored red. 
 
 Examination for Elastic Fibers. — 
 
 Take 8 c.c. of sputum and equal amount of 10 per cent 
 sodium hydrate, shake well and heat the mixture (but keep 
 below the boiling point) until whole mass is liquified. Dilute 
 with water, centrifugalize. Pour off supernatant fluid. Make 
 a thick smear on slide from the sediment and let it dry in the 
 air. Cover smear with Weigert elastic tissue stain and 
 steam for 4 minutes, but be careful to prevent alcohol from 
 catching fire. Wash gently in water. Decolorize for one 
 minute with 95 per cent alcohol. Wash in water. Dry and 
 mount and examine under dry lense for elastic fibers, which 
 appear blue and wavy. 
 
 An examination should be made for Curschmann's Spirals 
 and Charcot-Leyden Crystals in the sputum of every case of 
 
Sputum. 23 
 
 bronchial asthma. Use a two-thirds objective. The Cursch- 
 mann Spirals appear as twisted spirals of glossy transpar- 
 ency. Macroscopically they appear as twisted shreds about 
 1 m.m. thick and 1 to 2 centimeters long, and are composed 
 of mucous threads. The Charcot-Leyden crystals are not so 
 frequently present. They are transparent and octahedral 
 crystal. 
 
 Sputum in Disease. 
 Tuberculosis. — 
 
 In the early sfnyes, none at all or small in amount; occurs 
 most often early in the morning, and has a mucoiLS or slight 
 mucopurulent appearance. This may contain tubercle ba- 
 cilli. As the disease progresses it becomes more and more 
 mucopurulent, and finally purulent with cheesy-looking par- 
 ticles. It is then nummular in character. Amount of spu- 
 tum gradually increases from almost none in the early stages 
 to large quantities in the advanced stages. 
 
 Blood is present in almost all cases at some stages of the 
 disease. In early cases the sputum is only streaked with 
 blood, while larger hemorrhages are more apt to be seen 
 later. Cheesy particles are observed in the moderately ad- 
 vanced and advanced cases. They usually contain tubercle 
 bacilli in large numbers. 
 
 Sputum in Pneumonia. — 
 
 In young children and the very old often there is no ex- 
 pectoration. The sputum is at first mucoid, but sooner or 
 later becomes bloody to a greater or less degree, and in fully 
 one-third of the cases it is rusty in appearance. It is very 
 tenacious, and adheres to the cup when inverted. Prune 
 juice sputum is often, but not always an evil omen, as it in- 
 dicates a serious condition. 
 t 
 
 In cases of abscess or gangrene complicating the pneu- 
 monia, the sputum is more fluid; disagreeable odor especially 
 in gangrene, and the color is coffee-like or chocolate brown. 
 Microscopically one finds pus cells, epithelial cells, red blood 
 cells and pneumococcus. 
 
24 Diagnostic Methods. 
 
 Sputum in Bronchiectasis. — 
 
 Usually very abundant, and often mouthful at a time; 
 color is grayish-yellow, which may show red or brown pig- 
 ment; odor usually disagreeable, especially if putrefactive 
 changes have taken place in the bronchitic cavities. 
 
 Microscopically one finds pus cells, alveolar epithelial cells, 
 few red blood cells, and an immense number of bacteria. 
 
 Sputum in Bronchitis. — 
 
 Early in the attack the sputum is scanty, mucoid, and 
 highly tenacious, occasionally streaked with blood. As the 
 bronchitis continues the sputum becomes progressively more 
 purulent, which gives it a yellow color. 
 
 Microscopically one finds leucocytes, ciliated epithelial 
 cells, a few blood cells, and bacteria. 
 
 Sputum of Bronchial Asthma. — 
 
 During the paroxysm there is often no sputum. If pres- 
 ent it is scanty in amount, and occurs as grayish mucoid 
 masses. As the attack passes off sputum appears. It is then 
 fairly abundant, thin and frothy and contains mucopurulent 
 masses. The sputum contains Curschmann's Spirals, mucous 
 moulds of the smaller bronchi, and sometimes fibrinous casts. 
 
 Microscopically one finds many eosinophilic leucocytes, 
 which is of some diagnostic importance. Charcot-Leyden 
 crystals are often found. 
 
CHAPTER IV. 
 
 URINE. 
 
 Get (juaiitity in 24 hours. In suspected nephritis separate 
 day and night portions. Note color, odor, reaction, and spec- 
 ific gravity. 
 
 Preservation of Urine. 
 
 Specimens may be preserved by: 
 
 1. The addition of 40 per cent formalin in the propor- 
 tion of 30 drops to a liter of urine. 
 
 2. Cold storage. 
 
 3. Chloroform in the jDroportion of 20 drops to 4 ounces. 
 Use tightly corked bottle. 
 
 4. Thymol, 2 or 3 crystals to 4 ounces. 
 
 Turbidity. 
 
 Cloudiness of urine may be due to precipitation of phos- 
 phates, or urates, or may be due to pus, bacteria or fat. If 
 cloudiness is due to urates it will clear up on heating; if due 
 to phosphates, with a few drops of acetic acid; if due to fats 
 it will clear up by shaking with equal quantity of ether. If 
 due to bacteria, clear up by the addition of aqueous solution 
 of ferric chloride and then ammonium hydrate, and then 
 filter. Cloudiness from red blood cells, pus, bacteria and 
 cellular elements may be determined by microscopical exam- 
 ination. 
 
 Chemical Examination of the Urine. 
 
 A quantitative examination should be made for the fol- 
 lowing abnormal constituents of the urine: (a) any albumen, 
 (b) serum-albumen, (c) albumose, (d) nucleo-albumen, (e) 
 serum-globulin, (f) hsemoglobin, (g) bile, (h) indican, (i) 
 
 (25) 
 
26 Diagnostic Methods. 
 
 sugar, (j) acetone, (k) diacetic acid, (1) Beta-oxybutyric 
 acid, (m) Diazo su)3stances. 
 
 Chemical Test for Albumen. — 
 
 1. Nitric Acid or Heller's Test. — This reacts to all 
 urinary proteids except peptone. Place 5 c.c. or thereabouts 
 of colorless nitric acid in the bottom of a test tube. Incline 
 the test tube, and place in equal amount of clear filtered 
 urine with a pipette. A white precipitate of albumen forms 
 at the junction of the two fluids, if albumen is present in the 
 urine. A cloudy precipitate higher in the urine may be due 
 to urates. Bile and an excess of urinary coloring matter may 
 give a colored precipitate at the junction of the two fluids. 
 This is a very accurate test, as it shows fairly definitely even 
 to as small amount as 1/1000 of 1 per cent of albumen in the 
 urine. 
 
 2. Heat Test.' — Pour 10 c.c. of clear filtered urine into a 
 test tube and 1/10 of its volume of saturated sodium chlo- 
 ride solution may or may not be added, and then boil the 
 upper half of the fluid. Add 3 to 4 drops of 25 per cent 
 acetic acid and boil again. . A precipitate appearing on boil- 
 ing, which persists after the addition of the acid, or appear- 
 ing on the second boiling, is albumen. One disappearing with 
 the addition of the acid is phosphates. The test may fail if 
 too much acetic acid is added. This is one of the most deli- 
 cate tests for albumen. 
 
 Acetic Acid and Potassium Ferrocyanide Test. — 
 
 Make 8 or 10 c.c. of clear filtered urine strongly acid with 
 25 per cent acetic acid — 12 to 15 drops. Then add drop by 
 drop a 5 per cent solution of potassium ferrocyanide. A 
 white flocculent precipitate is formed if albumen is present. 
 
 Picric Acid Test. — 
 
 To 8 or 10 c.c. of clear filtered urine add a few drops of 
 Esbach's reagent. The appearance of a precipitate indi- 
 cates presence of albumen. 
 
 Chemical Tests for Serum-albumen. — 
 
 Add to a test tube half filled with filtered urine one-fifth 
 of its volume of a saturated aqueous solution of sodium chlo- 
 
Urine. 27 
 
 ride, heat to a boiling point ; add 2 to 5 drops of 50 per cent 
 acetic acid and heat again. The persistence of a precipitate 
 indicates serum-albnmen. 
 
 Chemical Test for Nucleo-albumen. — 
 
 Place in a test tube 5 c.c. of urine, and nearly fill test tube 
 with water. Divide this into equal parts. Use one as a con- 
 trol, and to the other add 4 drops of 50 per cent acetic acid 
 without heating. A cloudiness indicates the presence of nu- 
 cleo-albumen. 
 
 Chemical Test for Serum-globulin. — 
 
 Fill two test tubes about two-thirds with distilled water. 
 Use one as a control, and to the other add 10 drops of urine 
 drop by drop. A cloudiness indicates the presence of serum- 
 globulin. 
 
 Chemical Test for Albumose. — 
 
 Take 8 c.c. of urine and add nitric acid, drop by drop, till 
 you get a permanent precipitate. Heat to the boiling point 
 and the precipitate will partially disappear. Cool upper 
 part with water and it will reappear. Repeat this again till 
 you are sure it is albumose. The nitric acid converts the al- 
 bumen into an acid albuminate which is soluble, but the al- 
 bumose is not affected. 
 
 Chemical Examination for Hsemogiobin. — 
 
 To about 10 c.c. of urine in a test tube add 2 c.c. of glacial 
 acetic acid and 15 c.c. of ether. Shake gently for 1 or 2 min- 
 utes. After the ether has separated, decant. Add to the ethe- 
 rial solution 10 drops of a freshly prepared tincture of guaiac 
 and 30 drops of hydrogen peroxide. A blue color indicates 
 the presence of blood or blood coloring matter (hasmoglobin). 
 
 Chemical Examination for Bile. — 
 
 Iodine Test. (Tine, iodine 1 part, alcohol 15 parts.) Pour 
 2 c.c. of the iodine solution on the top of the urine in a test 
 tube. A green ring at the junction of the two fluids shows 
 bile. 
 
28 Diagnostic Methods. 
 
 Chemical Examination for Indican. — . 
 
 (1) To 8 or 10 c.c. of clear filtered urine add about 2 c.e. of 
 5 per cent copper sulphate solution, and 3 c.c. of chloroform, 
 and a quantity of concentrated hydrochloric acid equal to 
 number of c.c. already present. Invert test tube a few times 
 gently. The amount of indican present is proportional to 
 the depth of color of the chloroform extract. (2) To about 
 10 c.c. of clear filtered urine add equal quantity of concen- 
 trated hydrochloric acid which contains in 100 c.c. .4 gram 
 of ferric chloride. Shake well, then add 3 to 4 c.c. of chloro- 
 form and shake again. The chloroform will become blue if 
 indican is present. 
 
 Sugar. — 
 
 If albumen is present in more than a trace, the urine should 
 be acidified with several drops of 25 per cent acetic acid, 
 heated to precipitate the albumen and then filtered. 
 
 1. F Billing 's Test, — Add equal quantities of the copper 
 solution and alkaline solution. Dilute 3 to 4 times with wa- 
 ter. Boil the upper fourth of the Fehling's solution and 
 then add, at once, 1 or 2 drops of the urine. If sugar is 
 present you will get a reddish precipitate. Do not boil a sec- 
 ond time if there is no precipitate, but set aside for a few 
 hours and then examine for precipitate. If you should boil 
 a second time and then no reddish precipitate appears there 
 is no sugar present, but a reddish precipitate might then be 
 due to other things in the urine than sugar. 
 
 2. Phenyl-hydrazine Test. — To 5 c.c. of the clear filtered 
 urine add 5 c.c. of the phenyl-hydrazine acetate solution. 
 Heat to the boiling point in the water bath for 30 to 45 min- 
 utes, then allow it to cool gradually. Place some of the yel- 
 low precipitate on a slide and then examine microscopically 
 for the needle-like crystals of phenyl-glucosazone. Both glu- 
 cose and levulose give identical crystals. 
 
 3. Nylander's Test. — Add 1 c.c. of Nylander's reagent to 
 10 c.c. of clear filtered urine in a test tube. Boil upper part 
 2 or 3 minutes. If sugar is present the fluid assumes first a 
 yellow then yellowish-brown and finally an almost black 
 color, and after some time a black sediment forms. 
 
Urine. 29 
 
 4. Fermentation Test. — To some of the urine add a little 
 fresh yeast. Fill the tube provided for the purpose with the 
 mixture. In a second tube place water containing a little 
 yeast. In a third tube place some of the urine without yeast. 
 Place in a warm room, or in an incubator until the next day, 
 and note the presence of the CO2 gas. 
 
 5. Trommer's Test. — Add to 5 c.c. of the clear filtered 
 urine an equal volume of strong sodium hydrate solution, 
 then drop by drop a 1 per cent solution of copper sulphate 
 as long as the precipitate formed continues to dissolve read- 
 ily. Heat upper part, and a reddish-yellow precipitate 
 means the presence of glucose. 
 
 Acetone. — 
 
 To one-sixth of a test tube of urine add a crystal of sodium 
 nitro prusside. Make strongly alkaline with 10 per cent so- 
 dium hydroxide solution. Shake. The addition of a few 
 drops of glacial acetic acid gives a purple color to the foam 
 if acetone is present. 
 
 Diacetic Acid. — 
 
 Add a strong aqueous solution of ferric chloride to one- 
 third of a test tube of urine. A burgundy red color shows 
 the presence of diacetic acid. If this reaction takes place 
 after the urine has been previously boiled, it is not due to 
 diacetic acid. 
 
 Beta-oxybutyric Acid. — 
 
 In testing for diacetic acid, if the ferric chloride reaction 
 is strongly positive Beta-oxybutyric acid is probably pres- 
 ent. 
 
 Diazo Substances. — 
 
 To 5 c.c. of sulphanilic acid solution add 2 drops of a .5 
 per cent fresh solution of sodium nitrite. Add an equal 
 quantity of urine. Shake and add quickly 2 or 3 c.c. of 10 
 per cent ammonium hydrate solution. A carmine color, espe- 
 cially in the foam, shows a positive diazo reaction. If the 
 reaction is positive and the mixture is allowed to stand for 
 
30 Diagnostic Methods. 
 
 24 hours a precipitate forms, the upper margin of which ex- 
 hibits a green, greenish-black or violet zone. 
 
 Quantitative Examination of the Following Normal 
 Constituents of the Urine. 
 
 (a) Chlorides; (b) Urea; (c) Total acidity; (e) Total 
 solids. 
 
 Chlorides. — 
 
 Take 10 c.c. of clear, filtered urine; add to this 50 c.c. of 
 distilled water, 5 c.c. of 5 per cent ammonium iron alum solu- 
 tion, 10 c.c. of concentrated nitric acid, and 20 c.c. of stand- 
 ard silver nitrate solution. Increase the quantity to exactly 
 100 c.c. with distilled water, shake and filter ; measure out 50 
 c.c. of the filtrate in a beaker, and titrate with standard am- 
 monium sulphocyanate solution until a reddish-brown tint 
 first extends throughout the whole liquid. 
 
 The amount of sulphocyanate used multiplied by two gives 
 at once the excess of silver nitrate used beyond the quantity 
 required to precipitate all the chlorides in the 10 c.c. of 
 urine. Knowing the original number of c.c. of silver nitrate 
 taken, and the excess, the difference will give the number 
 used up, and each c.c. of this equals 10 mgms. of sodium 
 chloride. This is multiplied by (1/10) one-tenth of the 
 24-hour quantity of urine to get amount of sodium chloride 
 excreted in 24 hours. 
 
 Urea. — 
 
 Use Doremus-Hinds ureameter. Fill the large tube with a 
 mixture of sodium hydrate solution and bromine solution in 
 the proportion of 15 c.c. of the former to 1 c.c. of the latter. 
 Fill the smaller tube to the zero point with urine. Now very 
 gradually allow 1 c.c. of the urine to pass into the mixture 
 in the large tube. Urea is decomposed and nitrogen gas is 
 liberated and collects at the top. If the level of the fiuid 
 stands at .015, then 1 c.c. of the urine contained .015 grams 
 of urea. This must be multiplied by number of c.c. in 24- 
 hour quantity to get total quantity of urea passed in that 
 length of time. 
 
Urine. 31 
 
 The Doremus ureameter differs from the Doremus-Hinds 
 in that a 1 e.c. graduated pipette is non-attached and is 
 therefore less convenient. One c.c. of the urine is added to 
 the solution and after the bubbles of gas have ceased to rise, 
 make the reading and estimation in the same manner as the 
 above. 
 
 Total Acidity. — 
 
 Take 25 c.c. of urine, add to this 2 c.c. of saturated potas- 
 sium oxalate solution: then two or three drops of 1 per cent 
 phenolphthalin solution. Titrate this with decinormal so- 
 dium hydrate solution until the first change to red color takes 
 place. This represents the neutralization of all the acids in 
 25 c.c. of the urine. From this estimate quantity in a 24- 
 hour specimen. The normal is about 400 expressed in terms 
 of decinormal sodium hydrate solution. 
 
 Total Solids.— 
 
 This is estimated by multiplying the last two figures of 
 the specific gravity of a mixed 24-hour urine by 2.33. Then 
 multiply the product by the number of cubic centimeters 
 voided in 24 hours and divide by 1,000. This will give ap- 
 proximately the total solids expressed in grams. 
 
 Quantitative Examination of the Following Abnormal 
 Constituents of the Urine; 
 
 (a) Albumen; (b) Sugar; (c) Indican. 
 
 Albumen. — 
 
 An approximate idea of the quantity of albumen can be 
 obtained by boiling 10 c.c. of urine acidified with two drops 
 of 50 per cent acetic acid and allowing the albuminous pre- 
 cipitate to settle for 24 hours. If the albumen amounts to 
 2 or 3 per cent the fluid will be converted into an almost com- 
 pact coagulum. One per cent of albumen in the urine the 
 precipitate wall occupy half the column of urine, five-tenths 
 per cent of albumen will occupy one-third, one-tenth per 
 cent will occupy one-tenth the volume, five-hundredths per 
 
32 Diagnostic Methods. 
 
 cent will cover the bottom of the test tube. One-hundredth 
 per cent or less causes a turbidity, but no precipitate. 
 
 Method of Eshach. — This method, while not accurate, is 
 convenient and applicable. Fill the Eshach albuminometer 
 to the line, marked "U" with the urine, and fill to the line 
 marked "R" with Eshach 's reagent. Close the tube, and by 
 repeated inversions thoroughly mix the two fluids. Do not 
 shake. Set aside in natural position for 24 hours, when the 
 precipitated proteid will settle to the bottom. The gradua- 
 tions indicate the grams of proteids in a liter of the urine. 
 If amount of proteid is large, it will be necessary to dilute 
 urine. 
 
 Modification of Esdach. — This method differs from Es- 
 hach 's simply in the addition of 10 drops of a 10 per cent 
 ferric chloride solution to the measured amount of urine 
 after it is put in the tube, and before Eshach 's reagent is 
 added. Mix gently, and place the tube in a water bath at a 
 temperature of 72° C. Precipitation begins almost immedi- 
 ately and is complete in an hour or so, when the result is 
 read in the usual manner. 
 
 Tsuchiya's Modification of Eshach's Method. — Acidify 
 urine with a few drops of 25 per cent acetic acid. Fill Eshach 
 tube with urine to mark "U," and then Tsuchiya's reagent lo 
 mark * ' R. " Cork and invert 12 times to mix well. Place in 
 vertical position at room temperature for 24 hours, and then 
 read as in Eshach 's method. This test is excellent in many 
 respects. 
 
 Indican. — 
 
 To 10 c.c. of urine add 1 c.c. of 25 per cent lead acetate so- 
 lution. Filter. To 5 c.c. of the filtrate add 5 c.c. of Ober- 
 mayer's reagent (concentrated hydrochloric acid, 500 c.c. 
 ferric chloride, 1 gm.). Shake gently. Add 2 c.c. of chloro- 
 form. Shake and let stand for 5 minutes. A blue color indi- 
 cates the presence of indican. Now drop from a burette a 
 solution of potassium chlorate (34.64 gm. to a liter of water) 
 until the blue color disappears. It normally requires about 
 3 drops. If indicanuria is present it may require 10 to 15 
 drops or more. 
 
Urine. 33 
 
 Sugar: Fehling's Quantitative Method. — 
 
 Solution A. — Copper sulphate solution. Made by weigh- 
 ing out accurately 34.64 gnis. of purest obtainable copper 
 sulphate, and dissolve in exactly 500 c.c. of distilled water. 
 10 c.c. equals .05 gm. of glucose. 
 
 Solution B. — Alkaline tartrate solution. Dissolve 125 gms. 
 of sodium hydroxide, and 173 gms. of Rochelle salts in 500 
 c.c. of distilled water. Place 5 c.c. of the copper sulphate in 
 a moderately large flask, and add an equal volume of the al- 
 kaline tartrate solution. Dilute this with 5 or 6 volumes of 
 water, and bring to a boil. Fill a burette with urine to be 
 tested, and run it into the flask until the color of the solu- 
 tion has entirely disappeared. In the beginning of this titra- 
 tion .5 c.c. of urine may be added at a time with boiling after 
 each addition. Towards the end, when the blue color has al- 
 most disappeared, the urine should be added more cautiously, 
 2 or 3 drops at a time, not less than 5 c.c. of the urine should 
 be used. Urines richer in sugar should be diluted accord- 
 ingly. Three determinations should be made; the first for 
 an approximate estimate and to see the extent of dilution of 
 the urine ; the last two for a final determination, the average 
 being taken. 
 
 The amount of copper sulphate solution used is reduced 
 by .05 gm. of glucose. This amount of sugar, then, must 
 therefore be in the volume used for the titration. Calculate 
 the per cent. 
 
 Sugar: (Quantitatively) — Modified by Rudische. — 
 
 To 4 parts by volume of a 50 per cent solution of potas- 
 sium sulphocyanate, chemically pure, is added 1 part by vol- 
 ume of a mixture of equal parts of Fehling's copper sulphate 
 and alkaline solutions. Place 25 c.c. of this solution in a 
 beaker, and the urine to be tested added drop by drop from a 
 burette until the blue color of the copper entirely disap- 
 pears. Throughout the titration, the solution should be 
 slowly boiled and constantly stirred with a glass rod. The 
 end reaction is sharp, the fiuid becoming colorless or assum- 
 ing a faint yellow tinge. Each c.c. of the reagent is re- 
 
34 Diagnostic Methods. 
 
 duced by 1 M. gm. of sugar : therefore it takes 25 M. gms. of 
 sugar for the 25 c.c. of the reagent, and this amount of sugar 
 is present in the quantity of urine used in the titration. 
 
 Examination of the Urine for Bacillus Tuberculosis. 
 
 1. Centrifugalize, decant, dilute with water and recentri- 
 fugalize. Make a cover glass preparation from the sedi- 
 ment. This should be spread thinly and dried by holding 
 over the flame of a Bunsen burner. Fix by passing through 
 the flame three times. 
 
 2. Cover the preparation with carbol-fuchsin and steam 
 over a flame for 2 minutes. Do not let slide become dry, but 
 add more stain if necessary. 
 
 3. Wash in water. 
 
 4. Decolorize in acid alcohol until the red color is re- 
 moved and faint pink is seen. 
 
 5. Wash in water. 
 
 6. Cover with Loffler's methylene-blue for 30 seconds. 
 
 7. Wash in water and mount. 
 
 The tubercle bacilli are bright red; nuclei and other bac- 
 teria are blue. The alcohol decolorizes any smegma bacilli, 
 but absolute differentiation requires inoculation of guinea- 
 Pig- 
 
 Microscopic Examination of the Urinary Sediment. 
 
 Centrifugalize with hand, water or electric centrifuge, 
 and examine for crystals, fat globules, epithelial cells, red 
 blood cells, pus cells and casts. Use two-thirds and one-sixth 
 lens. 
 
 Epithelial cells are recognized by the presence of a nu- 
 cleus in the center of the cell. The cells may be of various 
 sizes and shape depending on whether they originate from 
 urethra, bladder, ureter or kidney. 
 
 Red cells are recognized by their spherical shape, and ab- 
 sence of nucleus. They may appear only as circular rings 
 or may contain some haemoglobin. 
 
Urine. 35 
 
 Piis cells (leucocytes) appear spherical and granular. On 
 addition of a drop of dilute acetic acid the nucleus will be- 
 come visible and its shape may be made out. 
 
 Casts are recognized by the following characteristics : 
 Their sides are parallel, their ends are square or somewhat 
 irregular, but they never come to a point. They are divided 
 into the following: 
 
 1. Hyaline casts; (a) narrow, (b) broad. 
 
 2. Granular casts; (a) finely granular, (b) coarsely gran- 
 ular. 
 
 3. Waxy casts. 
 
 4. Fatty easts. 
 
 5. Casts containing organized structures; (a) epithelial 
 casts; (b) blood easts; (c) pus easts. 
 
 Casts must be distinguished from mucous threads, and 
 eylindriods. Mucous threads show faint longitudinal stria- 
 tions and taper to a point at both ends. Cylindriods are 
 homogenous like hyaline casts, but one or the other end 
 tapers to a point. 
 
 Urine in Disease. 
 
 Acute Diffuse Nephritis. — 
 
 Quantity of urine very much diminished, depending of 
 course on its severity. 
 
 Specific gravity and color are correspondingly increased, 
 the color is often smoky from the presence of blood. In 
 other cases the microscope is required to demonstrate the 
 blood. Albumen is present in large amounts, 1/8 to 1 per 
 cent. 
 
 Microscopical examination shows the presence of hyaline, 
 granular and epithelial, and usually also blood and leuco- 
 cytie casts. In addition there are renal epithelial cells which 
 sometimes show evidence of fatty degeneration. Leucocytes 
 and red blood cells in varying numbers are seen. 
 
 Chronic Diffuse Nephritis (Large White Kidney). — 
 
 Urine diminished in quantity. Specific gravity and color 
 correspondingly increased. Albumen is always present and 
 
36 Diagnostic Methods. 
 
 usually in a greater amount than in the acute cases, the 
 amount varies from I/4 to 1 per cent. 
 
 Microscopically one finds hyaline, granular, fatty, waxy 
 and epithelial casts, renal epithelial cells undergoing ex- 
 tensive fatty degeneration, free fat globules, leucocytes and 
 a few red blood cells. If an acute exacerbation of chronic 
 diffuse nephritis occurs, then there is in addition to the 
 above, more blood cells and blood casts in the urine, the 
 quantity is more diminished and the oedema is much more 
 extensive. 
 
 Chronic Interstitial Nephritis (Granular Contracted 
 Kidney). — 
 
 The urine is increased in quantity, especially at night. It 
 is pale in color. Specific gravity is diminished, usually be- 
 tween 1,010 and 1,004. 
 
 Albumen is present in traces, but at times may not be 
 found. 
 
 The morning urine may be free from albumen but the 
 evening urine may contain it. It is necessary to centrifugal- 
 ize the urine to obtain sediment, and even then it is small in 
 amount. 
 
 Microscopical examination shows a small number of hya- 
 line and finely granular casts, an occasional epithelial cell 
 and a few leucocytes. 
 
 Renal Tuberculosis. — 
 
 Early in the case polyuria is of frequent occurrence. Often 
 the passage of blood is the first thing to attract the attention 
 of the patient. 
 
 The blood may be microscopic only, or macroscopic. It is 
 usually intermittent, the average length of the bleeding is 
 three days. The blood and the urine are intimately mixed. 
 Pus is frequent in all cases in which the pelvis of the kidney 
 is involved. Amount is very, variable, from a few leuco- 
 cytes to 14 the volume of the urine. As a rule this pyuria 
 is constant. 
 
 Albumen is of course always demonstrable whenever blood 
 or pus is present — the latter by itself is only responsible for 
 
Urine. 37 
 
 a trace; casts may be present, but they are not a constant 
 factor in the urinary picture, while the association of hema- 
 turia and pyuria with an acid urine should always excite 
 suspicion. 
 
 The diagnosis of renal tuberculosis demands the demon- 
 stration of the tubercle bacillus as well. 
 
 Arteriosclerotic Kidney. — 
 
 Urinary findings the same as in chronic interstitial ne- 
 phritis. 
 
CHAPTER V. 
 GASTRIC CONTENTS. 
 
 In an examination of stomach contents the material from 
 a fasting stomach and also the contents following a test meal 
 should both be examined. 
 
 It is best to obtain the contents of a fasting stomach early 
 in me morning, as in normal stomachs no food should be 
 present; if it is present it is a sign of stasis. If as much as 
 50 c.c. of fluid is obtained it indicates hypersecretion or 
 stasis. After removing the fasting contents the test meal 
 should be given. 
 
 Test Meal. 
 
 This consists of one large slice of bread and a glass and 
 one-half of water. Masticate the bread thoroughly. This 
 should be removed in one hour. Pour in 200 c.c. of water 
 and remove this as the lavage. 
 
 An objection to this test meal (Ewald's) is the presence 
 of a certain amount of lactic acid in the bread. A good sub- 
 stitute for the bread is one Shredded Wheat Biscuit. 
 
 Physical, Chemical and Microscopical Examination. 
 
 A physical, chemical and microscopical examination should 
 be made of the fasting contents and the test meal removed in 
 one hour. 
 
 Physical Examination. 
 Quantity. — 
 
 Measure amount of fasting contents, and the amount after 
 a test meal, which should be about 100 c.c, if 200 or 300 c.c. 
 either motor insufficiency or hypersecretion is probable. Note 
 proportion of fluid in the total quantity of contents, the food 
 residue should be about one-fourth. 
 (38) 
 
Gastric Contents. 39 
 
 Color. — 
 
 Coffee ground appearance suggests cancer. Reddish color 
 is due to blood and suggests ulcer. Green or yellow 'color is 
 due to bile. 
 
 Odor. — 
 
 The odor of butyric acetic and lactic acid and yeast is 
 characteristic of fermentative changes in the stomach. 
 
 Mucous. — 
 
 Large amounts suggest chronic gastritis. Small amounts 
 occur normally. 
 
 Chemical Examination. 
 
 Qualitative examination should be made for the following: 
 Free acids, combined hydrochloric acid, free hydrochloric 
 acid, organic acids (lactic acid), pepsin, rennin and blood. 
 
 1. Free Acids. — 
 
 Use Congo red paper. A blue color indicates the presence 
 of free acids. 
 
 2. Free Hydrochloric Acid. — 
 
 Topfer's Test. — Add to 5 c.c. of gastric contents two drops 
 of Topfer's solution. A carmine red color indicates free hy- 
 drochloric acid. 
 
 Gunzhurg's Test. — Mix a drop of this reagent with a 
 drop of gastric contents in a porcelain dish or on a glass slide. 
 Evaporate slowly over a flame. A bright red color at con- 
 tact indicates free hydrochloric acid. 
 
 3. Combined Hydrochloric Acid. — 
 
 When there is no free hydrochloric acid present it is im- 
 portant to know whether there is achylia gastrica (no free 
 nor combined hydrochloric acid) or merely hypo-acidity 
 (combined hydrochloric acid being present). 
 
 Take 10 c.c. of gastric contents. Add a pinch of barium 
 carbonate, which is insoluble. Evaporate in a porcelain dish 
 to dryness and fuse at a low red heat. 
 
40 Diagnostic Methods. 
 
 If hydrochloric acid combined with proteids is present, the 
 heat will liberate the hydrochloric acid and the chlorine of 
 the hydrochloric acid will unite with the barium of the 
 barium carbonate and form barium chloride. Allow this to 
 cool and add distilled water to the residue of the porcelain 
 dish. "When it is dissolved, filter. Divide the filtrate into 
 two parts. Add to one part a iew drops of a saturated solu- 
 tion of sodium carbonate. 
 
 A precipitate, which is barium carbonate, indicates com- 
 bined hydrochloric acid in the original. The other part of 
 the filtrate should be used as a control. 
 
 4. Organic Acids. — 
 
 Lactic. — Dilute an aqueous solution of ferric chloride with 
 water to a faint yellow color. Fill two test tubes about one- 
 third full with this solution. Use one tube as a control, and 
 to the other add 5 drops of gastric contents; an intensifica- 
 tion of the yellow color indicates lactic acid. 
 
 Uffelm,ann's Test for Lactic Acid. — Into a test tube pat 
 about y2 inch depth of 5 per cent carbolic acid. To this add 
 one drop of an aqueous solution of perchloride of iron, a 
 deep amethj^st color results. Dilute this ,with distilled water 
 until it can be seen through readily. Into a test tube ^^ 
 filled with this diluted reagent pour 5 to 8 drops of the gas- 
 tric juice. The amethyst color changes to a canary yellow 
 in the presence of lactic acid. 
 
 5. Pepsin. — 
 
 Take 10 c.c. of unfiltered stomach contents in each of two 
 tubes and to each tube add some albumen of a hard-boiled 
 egg. Add to one of the test tubes an equal amount of .4 so- 
 lution of hydrochloric acid, and to the other an equal amount 
 of water. No free hydrochloric acid should be present at 
 the beginning of the experiment. Place each in thermostat 
 for 24 hours and note the digestion of the egg albumen, which 
 means that pepsin is present. 
 
 6. Rennin. — 
 
 Take 10 c.c. of unfiltered stomach contents and neutralize 
 to litmus by adding 10 per cent sodium hydrate solution. 
 
Gastric Contents. 41 
 
 Take 10 c.c. of milk and boil to kill bacteria. Allow this to 
 cool. Add 5 c.c. neutral gastric contents to the 10 c.c. of 
 milk and put in water bath at body temperature for 30 
 minutes. A curdling of the milk indicates the presence of 
 rennin. It is well to take varying amounts of the gastric 
 contents, as this will indicate the quantity of the ferment. 
 
 7, Blood.— 
 
 A. Giiaiac Test. — Place 10 c.c. of gastric contents in a 
 test tube and add 2 c.c. of glacial acetic acid and 15 c.c. of 
 ether. Insert a cork and shake gently for several minutes. 
 After the ether has separated, decant. Add to the etheral 
 solution 10 drops of freshly prepared tincture of guaiac and 
 2 c.c. of hydrogen peroxide. A blue color indicates the pres- 
 ence of blood. 
 
 B. The following chemical test may also be used. Place 
 some of the material supposed to contain blood on a glass 
 slide, add to this a minute crystal of sodium iodide, and then 
 two drops of glacial acetic acid. Cover with cover glass and 
 warm gently over flame until bubbles appear. If blood is 
 present, crystals of hemin will easily be seen under high dry 
 lens. 
 
 Quantitative Examination. 
 
 Quantitative examination should be made for Free Hydro- 
 chloric Acid, Total Acidity, and Combined Hydrochloric 
 Acid. 
 
 Free Hydrochloric Acid. — 
 
 To 10 c.c. of unfiltered gastric contents add 3 drops of 
 Topfer's solution. Titrate with decinormal sodium hydrate 
 solution until the disappearance of the carmine red color. 
 This point represents the neutralization of the free hydro- 
 chloric acid in the contents used. 
 
 To estimate the quantity of free hydrochloric acid multiply 
 the number of c.c. of the decinormal sodium hydrate solu- 
 tion used in the titration by 10. This gives the amount of 
 free hydrochloric acid in 100 c.c. of gastric contents in terms 
 of decinormal sodium hydrate. The result may be expressed 
 
42 Diagnostic Methods. 
 
 in per cent of hydrochloric acid if the above quantity is mul- 
 tiplied by .00365, i. e. the quantity of hydrochloric acid 
 which is neutralized by 1 c.c. of decinormal sodium hydrate. 
 The normal quantitative values of free hydrochloric acid 
 vary between .07 and .18 per cent, or 20 to 50 c.c. of deci- 
 normal sodium hydrate per 100 c.c. of gastric contents. 
 
 Total Acidity. — 
 
 To the same contents in which the free hydrochloric acid 
 has already been neutralized, add 3 drops of a 1 per 
 cent alcohol solution of phenolphthalein. Continue the titra- 
 tion with decinormal sodium hydrate solution until a per- 
 manent red color is obtained. This represents the neutrali- 
 zation of all the acid constituents of the gastric contents 
 (free mineral, organic acids and combined acids). 
 
 To estimate the total acidity multiply the number of c.c. 
 of the decinormal sodium hydrate solution used from the be- 
 ginning of the titration up to this point by 10. This gives 
 the total acidity of 100 c.c. of gastric contents in terms of 
 decinormal sodium hydrate. The result may be expressed in 
 per cent hydrochloric acid by multiplying the above quan- 
 tity by .00365. The normal quantitative values of the total 
 acidity vary between .15 and .30 per cent, or 40 to 80 c.c. 
 decinormal sodium hydrate per 100 c.c. of gastric contents. 
 
 Combined Hydrochloric Acid. — 
 
 To 10 c.c. of gastric contents add 3 drops of a 1 per cent 
 solution of phenolphthalein. Titrate with decinormal sodium 
 hydrate solution until a pink color is obtained throughout. 
 Read off from the burette the number of c.c. of decinormal 
 solution required. Take another 10 c.c. of the gastric con- 
 tents and add 3 or 4 drops of a 1 per cent solution (aque- 
 ous) of alizarin as an indicator. Titrate with decinormal so- 
 dium hydrate solution until the yellow color has disappeared 
 completely and a purple color' appears. Read off from the 
 burette the number of c.c. of the decinormal sodium hydrate 
 solution required. Subtract the number of c.c. required 
 with alizarin as an indicator from the number required with 
 phenolphthalein as an indicator, and multiply by 10, and 
 
Gastric Go7itents. 43 
 
 this will give the amount of combined hydrochloric acid ex- 
 pressed in terms of decinormal sodium hydrate solution. 
 The indicator, phenolphthalein, reacts to free acids, acid 
 salts, and combined acids, but the indicator, alizarin, reacts 
 only to free acids and acid salts, but not combined acids. 
 
 Microscopical Examination. 
 
 This should be done in all fasting contents, which should 
 not be filtered. Examine for: (a) food particles, as muscle 
 fibers, starch cells, starch granules and fat globules, (b) mu- 
 cus, (c) red blood cells, (d) leucocytes, (e) sarcinge,. (f) 
 yeast cells, (g) bacteria, as Oppler-Boas bacillus. 
 
 Stomach Contents in Disease. 
 
 Gastric Cancer. — 
 
 Amount varies depending on whether or not there is a 
 stenosis. 
 
 Blood is present when there is ulceration, which may be 
 early or late in the disease. The color of the stomach con- 
 tents is not changed by small quantities of blood, and an ade- 
 quate chemical examination is necessary for the detection. 
 If much blood is present, and remains in the stomach for a 
 time, a coffee ground appearance is given to the stomach 
 contents. 
 
 In about 80 per cent of the cases there is no free hydro- 
 chloric acid present ; however when a malignant growth be- 
 gins on the base of an old ulcer the hydrochloric acid may 
 not only be normal in quantity but even excessive in amount. 
 
 When free hydrochloric acid is absent there is usually al- 
 ways a certain amount of lactic acid present. 
 
 Microscopically one often finds the Oppler-Boas bacillus 
 when lactic acid is present, and red blood cells may also be 
 found. 
 
 Gastric Ulcer. — 
 
 Seventy-five per cent of all cases show the presence of 
 blood, which may be in macroscopical amounts, or a chemical 
 
44 Diagnostic Methods. 
 
 I 
 examination may be required to demonstrate its presence. 
 Free hydrochloric acid is increased in about half the cases, 
 as is also the total acidity. Blood may be present in feces. 
 
 Gastric Neurosis. — 
 
 The findings are variable. Hydrochloric acid is some- 
 times increased and sometimes diminished. Pepsin is nor- 
 mal. 
 
 Chronic Gastritis. — 
 
 In early cases hydrochloric acid may be increased. It is 
 generally diminished in well marked cases, and is often ab- 
 sent in advanced cases. When absent lactic acid is present 
 in traces, mucus is present and is significant of the disease, 
 motility and absorption is generally deficient. 
 
 Achylia Gastrica. — 
 
 This is frequently the terminal stage of chronic gastritis. 
 There is an entire absence of hydrochloric acid, and a very 
 low total acidity. A small amount of lactic acid may be 
 present. The motility of the stomach is fairly good. This 
 condition is often associated with gastric carcinoma and per- 
 nicious anemia. 
 
CHAPTER VI. 
 BLOOD. 
 
 Examination of a Drop of Fresh Blood. — 
 
 Secure a drop of blood on a cover slip and drop same on 
 a slide and immediately examine microscopically. The slide 
 and cover slip must be absolutely clean to enable the blood 
 to spread in a very thin layer. Note size, shape and color of 
 red corpuscles. Note the leucocytes and the ameboid move- 
 ments of the polynuclear variety. Note the fibrin. One may 
 examine fresh blood for the malarial parasite, embryos of 
 filaria sanguinis hominis and the trypanosoma gambiense. 
 
 Haemoglobin. — 
 
 For an accurate estimation use the Sahli apparatus. The 
 haemoglobin is expressed in percentage, 100 per cent being 
 considered as the normal. 
 
 Estimation of Haemoglobin. — 
 
 By the Use of the Sahli Hmnometer. — Fill the graduated 
 tube to mark 10 with N/10 hydrochloric acid. Fill the 
 pipette up to the mark 20 cu. m.m. with blood. This is 
 quickly discharged into the N/10 hydrochloric solution. 
 Shake and let stand for one minute. Now dilute with water 
 until color matches that of the standard solution. The 
 height of the column is then read. This gives the hsemo- 
 globin percentage. 
 
 By the Talquist Scale of Colons. — A rather large drop of 
 blood is collected on one of the squares of filter paper that is 
 supplied in the book. The gloss is allowed to disappear, and 
 it is then placed under the perforation in one of the red 
 strips. It is moved until the color of the drop of blood cor- 
 responds with one of the shades of red. This represents the 
 
 (45) 
 
46 Diagnostic Methods. 
 
 hgemoglobin percentage of the blood. The results are inex- 
 act, but suffice for rapid bedside work. 
 
 Color Index. — 
 
 This is the quotient obtained by dividing the percentage of 
 haemoglobin by the percentage of red blood corpuscles, 5,000,- 
 000 red cells per cu. m.m. being considered as 100 per cent 
 of the corpuscles. Normally the color index is about one. 
 When the index is less than one it indicates that the average 
 corpuscle is poor in coloring matter, whereas with a high 
 color index the corpuscles are rich in hsemoglobin. 
 
 Making a Blood Smear. 
 
 A blood smear for purposes of staining is made on either 
 cover slip or slide. For delicate and accurate work the for- 
 mer is superior, but for all practical purposes the latter suf- 
 fices. 
 
 The slide or cover slip intended for the smear should be 
 first thoroughly cleansed with soap and water, rinsed in 
 clear water, and finally in about 50 per cent alcohol. It 
 should be rubbed dry with a clean cloth, care being used not 
 to touch the flat surface with the fingers, but only the sides. 
 
 Cleanse the lobe of the ear or end of the finger with soap 
 and water, and then alcohol. Usually alcohol alone will suf- 
 fice. Wipe dry and pierce with a surgical needle. Wipe 
 away the first few drops of blood. Touch the center of the 
 cover glass against the top of the blood drop and immediately 
 drop this on top of a clean cover slip. About the time the 
 blood ceases to spread draw them apart, but keep their sur- 
 faces parallel. 
 
 A smear may be made on a clean slide by getting a drop 
 near one end and with another slide gradually drawing this 
 drop over the slide. 
 
 Blood Counting. 
 
 For the purpose of counting erythrocytes or leucocytes, a 
 counting chamber and pipette are required. The pipettes for 
 red cells and white cells are graduated differently in order 
 
Blood, 
 
 47 
 
 to make the dilution satisfactory for the count, the red cells 
 requiring much greater dilution than the white cells. The 
 pipette for the red cells is marked 0.5 at half the distance of 
 the capillary tube and 1 at the upper end of the tube. Above 
 the bulb is the mark 101. If the blood is drawn only to .5, 
 as is customary, and then the diluting fluid to the mark 101, 
 then the red cells have a dilution of 1 to 200. If the blood is 
 drawn to 1 and the diluting fluid to 101, then the dilution is 
 1 to 100. 
 
 The pipette for the leucocytes is marked 0.5 at half the 
 distance of the capillary tube, and 1 at the upper part of the 
 
 BLOOD-COUNTING CHAMBERS. 
 
 
 
 innnni liiiiiii liiiiBiaHHl 
 
 II 
 
 
 1 
 
 1 
 
 ■II 
 
 1 
 
 =?=!= !■■■ " " \ !|'= 
 
 i 
 
 § 
 
 1 
 
 
 
 
 Turck. 
 
 ^1^1 
 
 1 ill ill 
 
 \wa^ 
 
 ■■■i 
 
 ] ill ill 
 
 \mmm 
 
 ^^■1 
 
 1 ill ill 
 
 IHHHI 
 
 ■ 
 
 i ill III 
 
 :: i;:l ::: 
 
 r :::: ::: 
 
 Hi iii 
 
 :::: :: 
 
 Mlil 
 
 IHi^ 
 
 1^ 
 
 1 III II 
 
 
 ■^^H 
 
 mill III 
 
 I^^^^H 
 
 ■■■■ 
 
 iiiiiii III 
 
 I^^^^H 
 
 ■^^■1 
 
 ill III mil 
 
 I^H^HI 
 
 Zappert-Ewing. 
 
 Thoma. 
 
 capillary tube. Above the bulb is the mark 11. If the blood 
 is drawn only to .5, as is customary, and then the diluting 
 fluid to the mark 11, then the leucocytes have a dilution of 
 1 to 20. If it is drawn to 1 and the diluting fluid to 11, then 
 the dilution is 1 to 10. 
 
48 Diagnostic Methods. 
 
 The counting chamber consists of a thick glass slide, on 
 the center of which is mounted a small circular glass disc 
 which is ruled according to either Thoma, Tiirck, or Zappert- 
 Ewing. This circular ruled disc is surrounded by a square 
 glass table mounted also on the slide. The glass table is ex- 
 actly 0.1 m.m. above that of the ruled disc. A moat sepa- 
 rates the table from the ruled disc. 
 
 The disc ruled according to Thoma is as follows : This con- 
 sists of five square millimeters. The central square milli- 
 meter, which is used for counting the erythrocytes, is subdi- 
 vided into 400 small squares. By means of double lines these 
 smallest squares are grouped into blocks of 25, a convenient 
 unit to employ in counting the red cells. For the leucocytes 
 all five square millimeters are counted and the average is one 
 square millimeter estimated. 
 
 The rulings according to Tiirck and Zappert-Ewing are 
 similar to that of Thoma, but in the latter two there are nine 
 square millimeters instead of five. These latter two differ in 
 ruling of the four corner squares. For the red count only 
 the central square millimeter with its 400 small squares is 
 used, while for the leucocytes all nine are counted and the 
 average taken. 
 
 The counting chamber ruled according to Tiirck is the 
 most serviceable and is the one the author recommends. 
 
 1. Red Corpuscles. — 
 
 Draw the blood into the blood pipette up to the mark 
 .5 and dilute with Hayden's solution up to the mark 101. 
 Mix thoroughly. Blow out two or three drops, then place a 
 drop in the center of the ruled glass piece of the counting 
 slide, and gently place on the cover slip. If a small amount 
 passes out into the moat it will not matter, but it should 
 not pass out under the cover slip, as this raises it to a greater 
 distance than .1 of a millimeter. -^ Examine for Newton's rings. 
 Count 'the red corpuscles in 25 small squares at each of the 
 four corners of the central ruled square, then multiply by 
 four, then by ten, and finally by the dilution 200. Repeat 
 the count and take the average. In making the count, cells 
 
Blood. 49 
 
 are often seen in the position across the lines so the rule is 
 to count the cells crossing the left and lower lines and not 
 counting those touching the upper and right lines. This 
 count gives the number of red blood cells in a cubic milli- 
 meter of blood. 
 
 2. White Corpuscles. — 
 
 Draw the blood into the blood pipette up to the mark .5 
 and dilute with 1 per cent acetic acid up to the mark 11. Mix 
 thoroughly. Blow out two or three drops, then place one 
 drop in the center of the ruled glass piece of the counting 
 .slide, and gently place on cover slip. If a small amount 
 passes out into the moat it will not matter, but it should not 
 pass out under the cover slip, as this raises it to a greater dis- 
 tance than .1 of a millimeter. Examine for Newton's rings. 
 Count the leucocytes in the several square millimeters, and 
 get the average in one. Multiply this by 10, then by 20. Re- 
 peat this and get the average. 
 
 Cleaning the Blood-counting Apparatus. — 
 
 (a) Covnting Chamher. — Clean this with water only. A 
 little soap may be used. Never use alcohol, ether or other 
 solvent, as the cement by which the ruled disc is fastened to 
 the slide may be dissolved. 
 
 (b) Pipettes. — Always clean immediately after using. 
 The following steps should be employed: (1) Blow out con- 
 tents. (2) Draw up into it distilled water and blow it out. 
 (3) Repeat this. (4) Draw up 95 per cent alcohol once or 
 twice and blow it out. (5) Repeat with ether, the last time 
 removing the rubber tubing and blowing out through the 
 large end. 
 
 Method of Staining Blood Smears. — 
 
 1. Let the specimen dry in the air. 
 
 2. Cover well with Wright's stain for one minute. 
 
 3. Add distilled water, drop by drop, until a delicate 
 metallic scum appears on the surface, usually 3 drops. 
 
 4. Leave this dilute stain on for 2 minutes. 
 
50 Diagnostic Methods. 
 
 5. Wash in distilled water about 5 seconds, or until the 
 preparation has a pinkish color. 
 
 6. Dry quickly, mount and examine. 
 
 Examine the red blood cells and note variations in size 
 (mikrocytes and makrocytes), and shape (poikilocytes). 
 Note loss of color (achromia). Stippling; i. e., appearance 
 of granules in the cell. Polychromatophilia. Note the ap- 
 pearance of blasts, either normoblasts or megaloblasts. 
 
 Examine the white blood cells (leucocytes). Make a dif- 
 ferential count by counting at least 200 white corpuscles. 
 
 Note the number and percentage of: 
 
 1. Polynuclear basophiles. 
 
 2. Polynuclear neutrophiles. 
 
 3. Polynuclear eosinophiles. 
 
 4. Small lymphocytes. 
 
 5. Large lymphocytes. 
 
 6. Large mononuclears. 
 
 7. Transitional. 
 
 Examine for myelocytes (neutrophilic, eosinophilic, or 
 basophilic). 
 
 Examine the blood plates. These appear with Wright's 
 stain as round or oval bodies stained purplish. They are 
 often found in clumps and are about one-third the size of a 
 red blood cell. 
 
 Examine for parasites. The malarial parasites will be 
 stained blue, are found in the red cells, and are seen to con- 
 tain brownish granules. Collections of pigment are often 
 seen in the white corpuscles. Look for crescents or ovoid 
 bodies, indicating sestivoautumnal malaria. Crescents are 
 stained pale blue, have pigment granules in center and the 
 remnant of a red cell about them. 
 
 Widal 's Serum Reaction. — , 
 
 Use a bouillon culture of bacillus typhosus 12 to 24 hours 
 old. Examination by high dry lens should show the bacilli 
 in active motion and unclumped. A growth on agar agar 
 about 24 hours old may also be used. 
 
Blood. 51 
 
 Get the blood from the patient in a glass tube drawn out 
 at both ends into a capillary tube. Usually 5 to 10 drops or 
 less are sufficient. Centrifugalize to throw corpuscles to bot- 
 tom. Drop 9 drops of physiological salt solution into a small- 
 size glass tube, and 19 drops into another. Add a drop of 
 the serum to each tube and mix thoroughly. Place a drop of 
 this diluted serum from each tube on two cover slips and add 
 a platinum loop of typhoid bacilli grown on bouillon to each 
 drop. This gives a dilution of 1 to 20, and 1 to 40 respect- 
 ively. Place cover slip on a hanging glass slide and examine 
 microscopically with a high power dry lens. 
 
 The serum reaction is regarded as positive when there is 
 complete clumping of the bacilli and absolute cessation of 
 motility. The time limit for the test is one hour, although 
 the agglutination often occurs within a few minutes. A re- 
 action at 1 to 20 is very suggestive, while a reaction at 1 to 
 40 can be accepted as conclusive evidence of typhoid infec- 
 tion. 
 
 Another method of securing the blood is by getting a large 
 drop on a glass slide and extracting the blood with water. 
 Place 5 or 6 drops of water on a large drop of blood and let 
 stand for 15 minutes. Then gently stir with a platinum loop, 
 but do not mix up the cells and fibrin in the extract. Take 
 one platinum loop full of this extract and add it to the same 
 quantity of a 12-hour bouillon culture of typhoid bacilli. 
 This gives an approximate dilution of 1 to 40. Examine this 
 for agglutination. 
 
 Blood Culture. — 
 
 This should be done in all cases of suspected septicemia. 
 The diagnosis of typhoid fever is earliest made by the detec- 
 tion of typhoid bacilli in the blood. The best culture media 
 for the typhoid and colon bacilli is sterilized ox bile, but for 
 cocci, glucose bouillon and glucose agar is the most suitable. 
 
 In a case of suspected typhoid fever remove a few c.c. of 
 blood from the vein of the arm and inject 1 c.c. in several 
 test tubes containing about 5 c.c. each of sterilized ox bile. 
 Shake gently, place in incubator for 24 to 36 hours, then in- 
 
52 Diagnostic Methods. 
 
 oculate a bouillon and agar tube, and after 24 to 36 hours note 
 the presence or absence of a growth. 
 
 In a case of suspected septicemia remove a few c.c. of 
 blood in the same manner as in the above, and inject 2 c.c. 
 each in 2 or 3 bottles or flasks of fresh glucose bouillon which 
 contains about 30 c.c. Also inject 2 c.c. in melted glucose 
 agar whose temperature is not more than 42°. Shake gently 
 in either case. Allow the agar to solidify, then place in in- 
 cubator at 37° C. for 24 to 48 hours and note the presence or 
 absence of a growth. The culture media may be placed in 
 six-ounce rectangular shaped bottles. 
 
 Changes in the Blood in Various Diseases. 
 
 Pernicious Anemia. — 
 
 Number of red blood cells usually greatly diminished. 
 The percentage of haemoglobin also diminished, but not to 
 the same extent as the number of red blood cells. Color in- 
 dex is therefore high, about 1. or 1+. Very many macro- 
 cytes (usually well stained), and many poikilocytes, are pres- 
 ent. Often there is seen granular degeneration, also poly- 
 chromatophilia. Variable number of nucleated red blood 
 cells, the predominating variety being the megaloblasts, al- 
 though normoblasts are often seen. Leucocytes in the ma- 
 jority of cases are somewhat diminished with relative in- 
 crease of the lymphocytes. 
 
 Acute Lymphatic Leukemia. — 
 
 Number of red blood cells more or less diminished. The 
 percentage of haemoglobin also diminished and more in extent 
 than the red blood cells. This gives a low color index. Very 
 often nucleated red blood cells, which are chiefly normo- 
 blasts, are seen. Leucocytes are more or less markedly in- 
 creased, from 50,000 to 250,000 per cu. m.m. The predom- 
 inating cell is the lymphocyte, the number of which fre- 
 quently exceeds 80 per cent, the majority being the large 
 lymphocyte. 
 
Blood. 53 
 
 Chronic Lymphatic Leukemia.— 
 
 Number of red blood cells diminished. The percentage of 
 haemoglobin is diminished to a greater extent than the num- 
 ber of red blood cells. The color index is therefore low. Nu- 
 cleated red cells are not so often seen as in the acute variety, 
 but they are frequently found. Leucocytes are very much 
 increased, the average being about 350,000 per cu. m.m. The 
 variety especially involved is the small lymphocytes, more 
 than 90 per cent being of this variety. 
 
 Spleno-Myelogenous Leukemia. — 
 
 Number of red blood cells more or less diminished. The 
 percentage of haemoglobin is also diminished, and to a greater 
 extent than the red blood cells. The color index is therefore 
 low. Many poikilocytes, stipple cells, macrocytes and micro- 
 cytes are present. Very many nucleated red cells are pres- 
 ent. These are chiefly normoblasts, but megaloblasts are 
 also found. Leucocytes are very much increased in number, 
 on an average of 350,000 to a cu. m.m. of blood, but the num- 
 ber runs from 150,000 per cu. m.m. to 600,000 or 700,000. 
 The type chiefly involved is the myelocyte, 40 to 60 per cent 
 of the leucocytes being of this variety. The neutrophilic, 
 eosinophilic and basophilic myelocytes are all present, but the 
 largest per cent is of the neutrophilic variety. 
 
 Chlorosis. — 
 
 The hgemoglobin is markedly diminished; the number of 
 red blood cells very slightly so and sometimes not at all. 
 Color index is always low. Achromia is marked, poikilo- 
 cytes, stipple cells, and occasionally a few normoblasts. The 
 leucocytes are not affected as to the number. There is usu- 
 ally a slight relative increase in the lymphocytes. This con- 
 dition occurs at about the age of puberty in young girls who 
 are very nervous. 
 
 Splenomegaly or Splenic Anemia. — 
 
 A condition characterized by enlargement of the spleen, 
 an anemia of a secondary type, without leucocytosis or lym- 
 phatic enlargement, and a gradual downward course. If there 
 is, in addition to the enlarged spleen, cirrhosis of the liver, 
 jaundice and ascites, the condition is called Banti's disease. 
 
CHAPTER VII. 
 
 SEROUS FLUIDS. 
 
 This includes both transudates and exudates. Transudates 
 are non- inflammatory. The specific gravity is 1008 to 1018, 
 with only a few cells and a small amount of albumen ; i. e., 
 .2 to 2 per cent. Exudates are inflammatory in origin. The 
 specific gravity is 1018 to 1026, larger number of cells and 
 a greater abundance of albumen, 2 to 6 per cent. 
 
 Serous Fluids. 
 
 The Serous Fluids Are : 1. Pleural. 2. Peritoneal. 3. Peri- 
 cardial. 4. Cerebrospinal. In examination of serous fluids 
 the methods that apply to one will apply to all. 
 
 Physical Examination. — 
 
 Note the color, turbidity, and take the specific gravity. 
 Note the amount of fibrin or clot, take reaction. 
 
 Chemical Examination. — 
 
 Qualitative and Quantitative tests for albumen. (See urine 
 for tests.) 
 
 Cytodiagnosis. — 
 
 This is important as a diagnostic method and consists in 
 a differential count of the cells in a transudate or exudate. 
 The following should be carried out : 
 
 1. Place fluid in centrifuge tubes and centrifugalize for- 
 3 minutes. 
 
 2. Pour off supernatant fluid. 
 
 3. Make smear from sediment in same manner as blood 
 smear. 
 
 4. Let this dry in the air. 
 
 5. Cover the slip with Wright's stain for 45 seconds and 
 then add 3 drops of water and let remain for 2 minutes. 
 
 (54) 
 
Serous Fluids. 55 
 
 6. Wash rapidly in distilled water. 
 
 7. Qnickly blot dry, using filter paper. 
 
 8. Mount and examine with an oil-immersion lens, and 
 count the different types of cells. 
 
 A predominance of polymorphonuclear leucocytes points 
 to an acute infection. 
 
 A predominance of lymphocytes usually means tubercu- 
 losis, but may mean parasyphilis or cerebrospinal syphilis. 
 
 A scarcity of cells, with a predominance of endothelial 
 cells, indicates a transudation. 
 
 Carcinoma of the serous membrane shows a predominance 
 of endothelial cells, but with large numbers of lymphocytes 
 and red blood cells. 
 
 Bacteria in Serous Fluids. — 
 
 Pour a few c.c. of the fluid into a flask of nutrient bouillon. 
 Incubate for 24 to 36 hours and then make smear on cover 
 slip and stain with Loffler's methylene blue or Gram's stain. 
 The technique of these staining processes has already been 
 given. 
 
 Make smear also as in the method for cytodiagnosis and 
 stain with Loffler's blue and Gram's stain. In this way bac- 
 teria are found. 
 
 Total Cell Count of Serous Fluids. — 
 
 Draw up to the mark I in the white cell pipette a 3 or 4 
 per cent solution' of glacial acetic acid tinged slightly with a 
 solution of gentian violet. Now draw up the serous fluid to the 
 mark II. Shake well, and blow out first 2 or 3 drops. Place a 
 drop on the center of the blood counting chamber, gently place 
 on cover slip, examine for Newton's rings, count the cells in 
 the different square millimeters on the counting chamber. Take 
 the average in one square m.m. Take 1/10 of this and add 
 back to the number. Now multiply by 10. This gives total 
 number of cells in cubic m.m. of the fluid. In spinal fluid 
 the number is normally from 2 to 10. In acute infections of 
 the meninges the number may run up into the thousands. 
 In tuberculous meningitis the number runs from 150 to 250 
 per cu. m.m. 
 
56 Diagnostic Methods. 
 
 In parasyphilitic lesions and cerebrospinal lues the num- 
 ber runs from 75 to 150 per cu. m.m. In the latter two dis- 
 eases there is a high percentage of lymphocytes, while in the 
 first there is a high percentage of polymorphonuclear neu- 
 trophiles. 
 
 NogucM's Butyric Acid Test for increase in the globulin 
 content of the cerebrospinal fluid. This test is based upon 
 the observation that in syphilitic and parasyphilitic affec- 
 tions of the central nervous system the globulin content is 
 increased. 
 
 The test is as follows : 
 
 Take .15 c.c. of the meningeal fluid, absolutely free from 
 blood, and add to it .5 c.c. of 10 per cent solution of butyric 
 acid in normal saline. Boil this a few seconds over a flame, 
 then quickly add .1 c.c. normal sodium hydrate solution and 
 boil for a few seconds longer. In the presence of an in- 
 creased globulin content a granular or flocculent precipitate 
 appears. This gradually settles to the bottom of the tube. 
 Usually 2 hours is given for the appearance of this gran- 
 ular precipitate. 
 
 Technique for the Performance of Lumbar Puncture. 
 
 Locate the intervertebral space on a line with the crest of 
 the ilium. This is usually the space between the third and 
 fourth lumbar vertebra. Cleanse with soap and water an 
 area about the size of the hand. Rub this area with alcohol, 
 and then it may or may not be painted with tincture of iodine. 
 Have patient on left side near edge of bed, with head and 
 shoulders slightly elevated on a pillow, and legs flexed well 
 at the hips. "With a sterile lumbar puncture needle, 6 to 8 
 centimeters in length, enter as near the center of the space 
 between the spinous processes of the third and fourth lum- 
 bar vertebrae as possible. (The author prefers to enter in 
 the mid line, but many others prefer to enter about 1/5 to 
 2/5 of an inch to the right or left of the mid line.) Pass the 
 needle about the distance of 4 centimeters with point inclined 
 slightly toward the head and if it strikes bone withdraw a 
 
Serous Fluids. ' 57 
 
 short distance and change slightly the direction of the point 
 of the needle, and continue this nntil you feel it pass 
 the dense dura mater into the spinal subarachnoidean space. 
 Withdraw the stilette and the spinal fluid will immediately 
 begin to drop out in rapid intermittent drops. If pressure 
 is very much increased it may escape in a stream. The fluid 
 should be collected in sterile test tubes. 
 
CHAPTER VIII. 
 INTESTINAL CONTENTS. 
 
 A Macroscopic, Chemical and Microscopic Examination of 
 the stools should be made whenever intestinal trouble is sus- 
 pected. Especially is this true in the South. 
 
 The examination of the stools is very much simplified if 
 the patient's diet is restricted for two or three days before. 
 The diet should consist of milk, toast, gruel, eggs, oatmeal, 
 butter, rare steak and potatoes. ' If this is not done then ask 
 the patient what he has been taking for the past two or three 
 days. 
 
 Macroscopic Examination. 
 
 .Note the color, quantity, frequency, consistency, odor, and 
 presence of mucus, blood, pus, curds, round worms, hook 
 worms, segments of tape worms, etc. 
 
 Color. — 
 
 The normal brown color is due to hydrobilirubin. Infants' 
 stools are normally bright or golden yellow. The color of 
 the stools varies with: (a) Food — light with milk or bread, 
 dark with blackberries, red with wine and exclusive meat 
 diet, etc., green with green vegetables, (b) Drugs — green 
 after administration of calomel, black after bismuth sub- 
 nitrate and iron, (c) Blood — if from stomach or duodenum, 
 tarry stools; if from colon or rectum, bright red. (d) Bile 
 — clay-colored from diminished secretions, obstruction to flow 
 of bile, and from unabsorbed fat. (e) The green color of 
 stools is pathological, and is due to the presence of bilirubin. 
 
 Quantity. — 
 
 This depends on amount and character of diet, and habits 
 of patient. 
 
 Frequency. — 
 
 Stools may be numerous but without fsecal material. Fre- 
 (58) 
 
Intestinal Contents. 59 
 
 queiit stools that come from colon are usually small; if from 
 small intestines, usually large. 
 
 Consistency. — 
 
 This depends on how long the faeces has remained in the 
 rectum. Frothy stools indicate intestinal fermentation. 
 
 Odor. — 
 
 This is important in infants. Normally it is slightly sour, 
 foul in proteid putrefaction, sour in acid fermentation, odor- 
 less in cholera infantum. 
 
 Mucus. — 
 
 This is usually indicative of inflammation of the large in- 
 testines. If it comes as a coating to the fseees, or as mem- 
 branous flakes, shreds or gelatinous clumps, it is from the 
 large intestines. If it is intimately mixed with the stools, it 
 is from the small intestines. 
 
 Blood.— 
 
 See under heading of "Color." 
 
 Pus.— 
 
 If in large quantities is due to an abscess rupturing into 
 intestines, or to ulcerative colitis. If leucocytes come from 
 above coecum they will be digested, and only the nucleus 
 will be seen. 
 
 Curds. — 
 
 These are often seen in infants' stools and are an indica- 
 tion of imperfect proteid digestion. 
 
 The stools should always be examined also for worms or 
 their segments. This is best done by taking a portion of the 
 fieces- and adding a little water until the stool is a thick 
 liquid, at the same time mixing the two together with a glass 
 rod or pestle, then place on a dark glass. Note also the pres- 
 ence of mucus or undigested food. 
 
60 Diagnostic Methods. 
 
 Chemical Examination. 
 
 Take reaction, examine for blood and bile. 
 
 Blood (occult). — 
 
 In performing this test it is best to withdraw meat from 
 the diet fop:* 3 days beforehand, as muscle fibers give a posi- 
 tive reaction for blood. 
 
 Guaiac Test. — Take about 5 c.c. of stool made liquid with 
 water unless already in a liquid state. Add 2 c.c. of glacial 
 acetic acid. Shake thoroughly and let it stand for 5 min- 
 utes. 
 
 In another test tube take pinch of powdered gum guaiac 
 and add to it 5 c.c. of 95 per cent alcohol, and let this stand 
 5 minutes. Filter. This makes tincture of guaiac. In the 
 test tube containing the stools and acetic acid add equal 
 amount of ether and invert tube carefully several times. 
 Decant the ether. Add to the ether extract tincture of 
 guaiac and hydrogen peroxide about 3 c.c. Shake, and if 
 you get a blue color it indicates the presence of blood. 
 
 Benzidine Test. — To a small amount of the faeces is 
 added an equal amount of water. Take 3 or 4 c.c. of this 
 and add to it 2 or 3 c.c. of alcoholic solution of benzidine 
 (made up by saturating 95- per cent alcohol with benzidine, 
 using some heat, then filter). Now add 1 or 2 c.c. of hydro- 
 gen peroxide and a few drops of acetic acid. In the pres- 
 ence of blood an intense green color develops. Occasionally 
 a light blue tinge. This test is extrepiely delicate. 
 
 Bile (hydro-bilirubin). — 
 
 Make the stool liquid by addition of water unless already 
 in a nearly liquid state. Take about 20 c.c. of this mixture 
 and to it add 20 c.c. of a concentrated aqueous solution of 
 corrosive sublimate. Shake well and set aside for 12 to 24 
 hours. Any facal particles that contain hydro-bilirubin are 
 colored red, and all particles with bilirubin assume a green- 
 ish shade. This test is also of value when you wish to tell 
 whether pale stools contain a large- amount of fat, or is due 
 to the absence of bile pigments. 
 
Intestinal Contents. 61 
 
 Microscopic Examination. 
 
 This includes food particles, epithelial cells, pus cells, 
 blood corpuscles, bacteria, ova and larvae of parasites. 
 
 The microscopic examination is rendered much easier if a 
 portion of the feeces is made liquid by the addition of wa- 
 ter, then filtered through one layer of gauze and centrifugal- 
 ized for a minute. Pour off the water and add more and mix 
 thoroughly with a glass rod. Centrifugalize for one-third 
 minute and again pour off the fluid. Repeat this a second 
 time. Now with a pipette, get the part from the bottom of 
 the centrifugal tube, place this on a slide and cover with 
 cover glass. This method is very useful when looking for 
 ova of intestinal parasites. 
 
 1. Food Particles. — 
 
 Examine for muscle fibers, starch granules, fat droplets 
 and fatty acid needles, which, if present, indicate defective 
 digestion of either proteid, carbohydrates or fats. The ad- 
 dition of Lugol's solution will color starch granules blue 
 and so enable one to identify them. Other things present 
 of little importance are vegetable fibers, vegetable cells, 
 starch cells, with or without granules. 
 
 2. Epithelial Cells. — . 
 
 These originate from the walls of the alimentary canal. 
 They are of no importance beyond their recognition. 
 
 3. Pus Cells.— 
 
 If intimately mixed with stools they are from high up the 
 intestinal canal. If only observed microscopically they in- 
 dicate a catarrhal or slight ulcerative condition. 
 
 4. Blood Corpuscles. — 
 
 This is best recognized by the chemical test. 
 
 5. Bacteria. — 
 
 The only one of practical importance is the bacillus tuber- 
 culosis. The method is as follows : Make a portion of the 
 stool fluid with water. Take 12 c.c. of this and centrifugal- 
 ize for 3 minutes. All the bacteria remain in the super- 
 
62 Diagnostic Methods. 
 
 natant fluid. Pour off this fluid and add equal amount of 
 95 per cent alcohol, which changes the specific gravity to 
 that lower than the bacteria. Centrifugalize a second time 
 and this throws down the bacteria. Pour off the superna- 
 tant fluid and then make a thin smear of the sediment on a 
 slide and stain in the usual method for the bacillus tuber- 
 culosis. 
 
 6. Ova of Intestinal Parasites. — 
 
 It is very important to recognize ova of the various in- 
 testinal parasites. The ova most commonly found in the 
 fffices are ova of the following: Oxyuris vermicularis, as- 
 caris lumbricoides, trichocephalus dispar, uncinaria, tsnia 
 saginata, taenia nana, bothriocephalus latus, and taenia so- 
 lium. 
 
 1. Ova of Oxyuris Vermicularis are often not found in the 
 fseces. They are oval with rounded end and flattened on one 
 side. In order to make a more accurate test for ova of this 
 parasite, either scrape the mucous membrane of the rectum 
 for material to examine microscopically, or give a cathartic 
 and examine the fluid discharge. 
 
 2. Ova of Ascaris Lumbricoides. — They are oval in shape 
 and brown or yellow from bile. The protoplasm is not seg- 
 mented and is granular, and margin is uneven or wavy. 
 
 3. Ova of Trichocephalus Dispar. — They are oval, yellow- 
 brown in color, and have a projection from each end which is 
 the characteristic point. 
 
 4. Ova of JJncinaria. — They are oval in shape, not bile- 
 stained, a transparent shell and a protoplasm usually divided 
 into from 2 to 8 segments. 
 
 5. Ova of Tmnia Saginata. — They are oval in shape, 
 contain booklets in their protoplasm and a shell which is radi- 
 ally striated, 
 
 6. Ova of Tcenia Nana. — They are spherical, have a thick 
 shell, which is usually in layers. 
 
 7. Ova of Bothriocephalus Latus (rare in this country).— 
 They are oval in shape, brown in color, and have an operculum 
 at one end. 
 
Intestinal Contents. 63 
 
 Intestinal Parasites Recognized by the Parasite Itself, 
 Portions of a Parasite, or Larvae. — 
 
 Intestinal Parasites that are recognized in the stool by 
 the parasite itself, portions of a parasite or larvge are : 
 Amoeba coli and cercomonas hominis (protozoa), segments of 
 the different types of tape worms, ascaris lumbricoides, 
 oxyuris vermicularis, uncinaria, larva of strongyloides intes- 
 tinalis, larvee of the house fly and trichina spiralis (rarely). 
 
 1. Amceha Coli (protozoon). — Secure the grayish or blood- 
 streaked particles from a fresh stool passed into a warm 
 vessel or by removal with a rectal tube. Place on a warm 
 slide and immediately examine microscopically for their 
 irregular amoeboid movements. 
 
 2. Cercomonas Hominis (protozoon). — This organism is 
 occasionally seen in fresh, warm stools, and if examined micro- 
 scopically it is motile. It is oval in shape and contains 
 flagella at one end. It is of no pathological significance. 
 
 3. Segments of Tape Worms. — Small segments are passed 
 at intervals if an individual is infected with any of the 
 types. 
 
 4. Ascaris Lumht'icoides. — They are passed occasionally 
 and as round worms are easily recognized. 
 
 5. Oxyuris Vermiculans. — Occasionally found in the 
 fgeces and about the anus of children. 
 
 6. Uncinaria. — Not often found in faeces. Give thymol, 
 followed by magnesium sulphate, and they then may be usu- 
 ally found in an infected patient. 
 
 7. Strongyloides IntestinaUs. — In this neither the para- 
 site nor ova are found in the faeces, but the ova hatch in the 
 intestines, and the actively motile larvae may be seen. The 
 stools should be examined microscopically while fresh and 
 warm. 
 
 8. Larvce of the House Fly. — The ova of the house fly 
 may be ingested, and these hatch in the intestines. The larva, 
 or maggots, may be found in the faces as a result. 
 
 9. Trichina Spiralis. — The worm itself may be rarely 
 found in the faces, but the diagnosis is best made by the 
 eosinophilia and the encysted larva in the muscles. 
 
CHAPTER IX. 
 TUBERCULIN DIAGNOSIS. 
 
 This is employed in three ways : 
 
 1. Koch's subcutaneous method. 
 
 2. Cutaneous reaction of Von Pirquet, and Moro Oint- 
 ment. 
 
 3. Ophthalmo reaction of Calmette. 
 
 Tuberculin is made by growing for 4 to 6 weeks a pure 
 culture of bacillus tuberculous in 5 per cent glycerine 
 bouillon. This is filtered, and the filtrate evaporated to 1/10 
 of its volume. This resultant fluid is known as the tuberculin. 
 
 Koch's Subcutaneous Method. 
 
 This is given subcutaneously in the back below the angle 
 of the scapula. Ordinarily for the first injection 0.2 m. gm. 
 is given ; if no evidence of a reaction in 2 or 3 days a second 
 injection of 1 m. gm. is given ; in 2 or 3 days more 5 m. gms. 
 are given, and finally 10 m. gms. Physiological salt solution 
 is used as the diluting fluid. 
 
 The chief evidence of a positive reaction is fever, at least 
 .5° C. or more. Other less important signs are: headache, 
 malaise, insomnia, and nausea. A focal reaction may occur 
 at the location of the tuberculous lesion. A local reaction 
 may take place at the point of injection. 
 
 Indications for Use of this Method. — 
 
 In adults with clinical symptoms, or clinically suspicious 
 symptoms of tuberculosis, but who are devoid of the pres- 
 ence of tubercle bacilli and temperature. 
 
 Contra-Indications. — 
 
 Fever, haemoptysis, h^ematuria, marked cardiac or renal 
 affection, arteriosclerosis, and diabetes. The patient should 
 (64) 
 
Tuberculin Diagnosis. 65 
 
 be placed in bed 2 or 3 days before the injection and tem- 
 perature taken every 3 hours to be certain no fever is present. 
 The patient should be kept in bed for 2 or 3 days following- 
 each injection. 
 
 Diag-nostic Value. — 
 
 A negative reaction following injection of 5 m. gms. is a 
 very strong point against the presence of a tuberculous 
 lesion in the body. A positive reaction indicates the pres- 
 ence of a tuberculous lesion, but whether it is an active pro- 
 gressive one or a latent lesion is difficult to say. 
 
 Von Pirquet Cutaneous Reaction. 
 
 Cleanse the patient's forearm on the inner surface Avith 
 ether. Place two drops of undiluted tuberculin upon the 
 skin 10 cm. apart. Scarify the skin first between the drops 
 as a control, and then scarify within the two drops. ■ Place 
 on a piece of cotton for about 10 minutes. 
 
 Interpretation of Reaction. — 
 
 Scarification of itself produces the so-called "traumatic 
 reaction," i. e., a small wheal with rose colored margin. 
 This passes away after several hours. The "specific reaction" 
 is noticed upon the upper and lower points where the tuber- 
 culin has been applied and consists of a red indurated papule, 
 which often extends in size 10 to 30 m.m. in diameter. This 
 occurs within 24 hours. 
 
 Diagnostic Value. — 
 
 In adults it is void of any diagnostic value, as 70 per cent 
 of all adults give a positive reaction. Between the ages of 
 10 and 15 about 50 per cent of all cases react positively. It 
 is of some value in children less than 10 years of age, and 
 of very considerable value in children younger than 5 years. 
 
 Moro Ointment Reaction. 
 
 A quantity of 50 per cent ointment of tuberculin about 
 the size of a pea is warmed lo 25° C, and this is rubbed into 
 the skin of the abdomen for about one minute. A papule or 
 
66 Diagnostic Methods. 
 
 small nodular eruption occurring within 24 or 36 hours is 
 regarded as positive. The diagnostic value is variously inter- 
 preted;, and it possesses in this respect about the same value 
 as Von Pirquet's reaction. 
 
 Ophthalmo Reaction of Calmette. 
 
 For this a one per cent fresh dilution of tuberculin in 
 physiological salt solution is made. Place one drop of diluted 
 tuberculin in the inner angle of the eye and let it run on the 
 inner surface of the lower lid. In 24 hours, if mucosa of 
 the lower lid is red and infected, the test is positive. This 
 test is of particular value in all suspicious cases of tubercu- 
 losis where the presence of bacilli can not be demonstrated, 
 and the subcutaneous reaction can not be undertaken on ac- 
 count of the presence of fever. It is used often in Vienna on 
 ambulatory patients without any bad results whatsoever. 
 
 Oontra-Indications. — 
 
 It is contra-indicated in all diseases of the eye, tubercu- 
 lous or otherwise. In case a second instillation is to be 
 given the other eye should be used. This is sometimes done 
 when there is no reaction with a one per cent solution. In 
 this instance a two per cent or even three per cent may 
 be used. 
 
 Diagnostic Value. — 
 
 A positive reaction indicates in about 80 per cent of the 
 cases the presence of tuberculosis, but as to whether the 
 tubercular condition is active or latent it is impossible to say. 
 
CHAPTER X. 
 
 THE WASSERMANN REACTION. 
 
 Preliminary preparation and tests for the Wassermann 
 reaction are: 
 
 1. Preparation and standardization of the amboceptor. 
 
 2. Preparation and standardization of the antigen. 
 
 3. Obtaining and preparation of the complement. 
 
 4. Obtaining and preparation of control and suspected 
 sera. 
 
 5. Preparation of diluting fluid. 
 
 6. Obtaining and washing sheep's red blood cells. 
 
 Preparation of Amboceptor. — 
 
 Inject into the peritoneal cavity of a large rabbit gradually 
 increasing quantities of washed sheep's red blood cells sus- 
 pended in 0.8 per cent salt solution. Inject the first time 
 2 to 3 c.c. of the cells, in four days 3 to 4 c.c, in four days 
 again 4 to 5 c.c, etc. About five or six injections are 
 required. Five or six days after the last injection administer 
 a little ether to the rabbit and dissect out the carotid artery, 
 and collect the blood in two 50 c.c. graduates. Place on ice, 
 and when the serum has separated, draw the serum off and 
 place in 5 c.c. quantities in small size test tubes. The entire 
 procedure must be carried out in a sterile manner. Place the 
 test tubes containing the serum in a water bath at a tempera- 
 ture of 56 degrees Centigrade, and maintain this for 30 
 minutes. This inactivates the serum, i. e., destroys, the com- 
 plement. 
 
 Standardization of the Amboceptor. — 
 
 Have six test tubes of about 10 c.c. capacity in a row, and 
 number same reading from left to right as follows: I, II, 
 III, IV, V, VI. Test tube I should have a capacity of at 
 least 15 c.c. In test tube I place 0.1 c.c. of the amboceptor, 
 
 (67) 
 
68 Diagnostic Methods. 
 
 then 0.9 c.c. of 0.8 per cent salt solution, and 9 c.e. of 0.8 per 
 cent salt solution. This gives a dilution of 1 to 100. Carry 1 c.c. 
 from this and place in test tube II, then add 1 c.c. of 0.8 per 
 cent salt solution. Mix well. This gives a dilution of 1 to 200. 
 Carry 1 c.c. from tube II to tube III and add 1 c.c. of 0.8 per 
 cent salt solution. This gives a dilution of 1 to 400. Continue 
 this process to tubes IV, V, and VI, which will give a dilu- 
 tion of 1 to 800, 1 to 1,600, and 1 to 3,200 respectively. Throw 
 away 1 c.c. from the last tube. Now add 2 c.c. of 0.8 per 
 cent salt solution to tubes II, III, IV, V, and VI; then add 
 to same tubes 1 c.c. of complement, diluted 1 to 10 with 0.8 
 per cent salt solution. To the same tubes now add 1 c.c. of 
 5 per cent sheep's red blood cells in 0.8 per cent salt solution. 
 Place in the incubator at 371/2 degrees Centigrade for 30 
 minutes and note the extent of complete hgemolysis, using a 
 dilution of the amboceptor between this dilution and the 
 dilution in the pre\aous tube. For example, if haemolysis is 
 complete in the 1 to 800 dilution and not present in the 1 to 
 1,600 dilution, then the strength to use is 1 to 600. This is the 
 dilution to be used in the Wassermann test, and 1 c.c. is the 
 quantity used. 
 
 Preparation of the Antigen. — 
 
 Get a fresh heart from a healthy beef. Remove endocar- 
 dium and epicardium. From heart muscle scrape off 30 
 gms. and place this in 270 gms. (by weight) of 95 per cent 
 alcohol. Shake as often as possible for 24 hours and keep 
 at room temperature. Then filter this through ordinary 
 filter paper. This filtrate contains the antigen to be used in 
 the test. 
 
 Standardization of the Antigen. — 
 
 HaA^e six test tubes of about 10 c.e. capacity, and number 
 these I, II, III, IV, V, and VI. In tube I place 0.1 c.c. of 
 antigen, in tube II place 0.2 c.c. of antigen, in tube III place 
 0.3 c.c. of antigen, 0.4 c.c. in tube IV, 0.5 c.c. in tube V, and 
 0.6 c.c. in tube VI. Add to each tube 2 c.c. of 0.8 per cent 
 salt solution. Then add 1 c.c. of the diluted amboceptor, 
 usually 1 to 500, or 1 to 600 dilution, and next 1 c.e. of 
 
The Wassermann Reaction, 69 
 
 complement diluted 1 to 10 with 0.8 per cent solution, and 
 finally to each tube 1 c.c. of 5 per cent sheep's red blood 
 cells. Shake well. Place in incubator at 37^^ degrees cen- 
 tigrade for one-half hour. Examine to see what strength 
 of antigen was inhibitive to haemolysis. Usually 0.15 c.c. 
 and 0.2 c.c. of antigen is used, as this is found practically 
 always to be noninhibitory to hemolysis. 
 
 Obtaining the Complement. — 
 
 This is done by removing all the hairs from the under 
 surface of the neck of a guinea-pig, and with scissors sever- 
 ing the vessels in the neck and catching the blood in a petri 
 dish. A better method is to dissect out the carotid artery, 
 and bleed into several test tubes. This blood is placed in 
 ice chest, and the serum allowed to separate off. This 
 serum is pipetted off and placed in test tubes. It may be 
 necessary to centrifugalize to separate off all the serum. 
 
 Preparation of the Complement. — 
 
 Dilute the complement in the proportion of 1 c.c. of 
 guinea-pig's serum to 10 c.c. of 0.8 per cent salt solution. 
 The complement should ahvays be fresh. 
 
 Obtaining of Patient's Sera for Test. — 
 
 Cleanse well the arm at the beud of the elbow, insert a 
 needle into a prominent vein, and allow 4 or 5 c.c. of blood 
 to pass into a test tube. Place in ice chest and allow the 
 serum to separate. Place this at once into another test 
 tube and inactivate by placing in a warm water bath at 56 
 degrees centigrade for 30 minutes. All this work should 
 be done in a sterile manner. 
 
 Diluting Fluid. — 
 
 This fluid is 0.8 per cent salt solution. Use C. P. sodium 
 chloride dissolved in distilled water. 
 
 Obtaining and Washing Sheep Red Blood Cells. — 
 
 Sheep red blood cells are obtained and washed in the 
 following manner : 
 
70 Diagnostic Methods. 
 
 Clip wool from the neck of sheep in the region of jugu- 
 lar vein. Shave this area. Place a cord about neck of 
 sheep directly in front of front legs and tighten same so as 
 to distend the veins. With a needle 5 or 6 centimeters long 
 pass into vein and allow the blood (10 or 15 c.c.) to pass 
 into a wide mouth bottle containing about 15 c.c. of 1 per 
 cent sodium citrate solution in 0.8 per cent sodium chlo- 
 ride solution and a dozen glass pearls. Shake gently for 
 several minutes. This is to prevent any clotting. Place in 
 centrifugal tubes and centrifugalize about 8 minutes. With 
 pipette draw off the supernatant salt and citrate solution. 
 Pour in equal quantity of 0.8 per cent sodium chloride solu- 
 tion. Mix well with pipette. Repeat this process a second 
 and a third time. The cells are now washed red blood celk. 
 After the third washing add same amount 0.8 per cent salt 
 solution as the red blood cells ; this is the approximate 
 quantity of blood serum. Two or three c.c. of this sus- 
 pended in a little 0.8 per cent salt solution is used for the 
 first injection into the rabbit. A 5 per cent solution is 
 used in the standardization of the antigen and amboceptor, 
 and also in the Wassermann test itself. 
 
 Technique of the Wassermann Test. 
 
 Have a front, middle and rear test tube for each serum to 
 be tested, also for positive control, negative control, and 
 antigen control. In the front tube place 0.6 c.c. of the 
 serum, then add to this 2.4 c.c. of 0.8 per cent sodium 
 chloride solution. i\Iix well and then place 1 c.c. of this 
 in the middle tube and also in the rear tube. This gives 
 0.2 c.c. of serum in each tube. Treat all the sera to be 
 tested, and also positive and negative control, in this man- 
 ner. In the antigen control tube place 1 c.c. of 0.8 per cent 
 salt solution in front, middle and rear tubes. 
 
 In all of the tubes of the front row place 1 c.c. of 10 per 
 cent complement, also 0.15 c.c. of antigen, 0.85 c.c. of 0.8 
 per cent salt solution. 
 
 In all of the tubes of the middle row place 1 c.c. of 10^ 
 per cent complement, also 0.2 c.c. of antigen, and 0.8 c.c. 
 of 0.8 per cent salt solution. 
 
The Wasserniann Reaction. 71 
 
 In all of the tubes of the rear row place 1 c.c. of 10 per 
 cent complement and 1 c.c. of 0.8 per cent salt solution, but 
 no antigen. 
 
 Shake well. Then place all the tubes in the incubator at 
 37 degrees centigrade for one hour. In this time union be- 
 tween the antigen and syphilitic antibody ( ?) will have 
 taken place in case the patient has syphilis, and so doing, 
 fixes the complement. 
 
 In one hour this is removed from the incubator and 1 c.c. 
 of the 1 to 500 (usually thereabo.uts) dilution of the ambo- 
 ceptor is added to every tube, and also 1 c.c. of the 5 per 
 cent suspension of the red blood cells. The antigen quan- 
 tity in the antigen control tubes is doubled. This is shaken 
 well, returned to the incubator for no longer than 30 min- 
 utes, or until the controls come out properly. 
 
 Interpretation. — 
 
 Hsemolysis should occur in the negative control tubes, 
 also in the three antigen control tubes. The rear row of 
 tubes should show haemolysis. If any one of these fail 
 to do so, the test on that serum should not be reported, bat 
 must be repeated. Positive control tubes should show the 
 complete absence of hemolysis. All the sera in which the 
 two front tubes show the absence of haemolysis are positive. 
 All the sera showing complete hgemolysis are negative. The 
 extent of the inhibition of hgemolysis varies from slight in- 
 hibition to complete inhibition. Therefore Ave say the Was- 
 sermann test is weekly positive, positive, or strongly posi- 
 tive, this being indicated by a single plus (-|-), a double 
 plus (-| — |-), or a triple plus (-| — | — |-), respectively. 
 
CHAPTER XI. 
 COMPLEMENT FIXATION TEST FOR GONORRHEA. 
 
 In this test the haemolytic system is used as in the "Was- 
 sermann reaction. The amboceptor is prepared and stand- 
 ardized exactly as in the Wassermann test. The comple- 
 ment is also obtained and prepared in the same manner, as 
 is also the control and suspected sera. The sheep red blood 
 cells are obtained and prepared exactly as in the "Wasser- 
 mann test. The antigen used by the author at the pres- 
 ent time is that prepared by Parke, Davis & Company. 
 
 The test is as follows : 
 
 Have two rows of test tubes — a front row and a back 
 row. In each tube of the front row place; the following: 
 1 drop of undiluted antigen, 17 drops of 0.8 per cent salt 
 solution, and 10 drops of complement diluted 1 to 10. In 
 each tube of the rear row place the following : 18 drops of 
 0.8 per cent salt solution, 10 drops of complement diluted 
 1 to 10. Finally place in a front tube and the correspond- 
 ing rear tube 2 drops of inactivated patient's serum. Re- 
 peat this in other tubes with inactivated positive serum, 
 and also with inactivated negative serum. 
 
 This should be placed in the incubator at 3714 degrees 
 centigrade for 30 minutes. Remove from incubator and 
 place in each front tube 10 drops of the diluted amboceptor, 
 the unit of Avhich has been determined according to the 
 method given in the Wassermann reaction, and 10 drops of 
 5 per cent Avashed sheep corpuscles. In each rear tube place 
 also : 10 drops of diluted amboceptor and 10 drops of 5 per 
 cent sheep corpuscles. 
 
 Place in the incubator at 37^2 degrees centigrade and in- 
 cubate until controls come out properly, i. e., all rear tubes 
 should show complete htemolysis. The front tube of the 
 (72) 
 
Test for Gonorrhea. 73 
 
 positive control should show the absence of hsemolysis. The 
 front tube of the negative control should show hgemolysis. 
 Therefore, any sera showing the lack of hasmolysis is re- 
 garded as positive, any showing the presence of haemolysis 
 is regarded as negative. 
 
CHAPTER XII. 
 
 APPARATUS AND CHEMICAL REAGENTS NECESSARY 
 FOR A PHYSICIAN'S LABORATORY. 
 
 Apparatus Necessary. 
 
 Microscope, with oil immersion, two-thirds and one-sixth 
 objective; Centrifugal machine; Blood counter; Tallquist's 
 haemoglobin scale ; CoA^er glasses and slides ; Burette ; For- 
 ceps ; Graduate ; Specific gravity bulb ; Doremus-Hinds 
 urea apparatus; Test tubes; Red and blue litmus; Congo 
 paper ; Beakers ; Flasks ; Blood lancet ; Filter stand ; Es- 
 bacli's tube; Funnels; Stomach tube; Pipettes; "Water bath. 
 
 Chemical Reagents Needed. 
 
 Concentrated nitric acid; Concentrated sulphuric acid; 
 Concentrated hydrochloric acid ; Glacial acetic acid ; 50 per 
 cent acetic acid; 25 per cent acetic acid; .5 per cent sodium 
 nitrate ; 10 per cent ammonium hydrate ; Decinormal sodi- 
 um hydrate ; 10 per cent sodium hydrate ; Sodium nitro- 
 prusside crystals ; Aqueous solution of ferric chloride ; Io- 
 dine solution (tincture iodine 1 part and alcohol 15 parts'* ; 
 20 per cent lead acetate solution; Saturated sodium chlo- 
 ride solution ; Saturated corrosive sublimate solution ; Con- 
 centrated hydrochloric acid with .4 gm. of ferric chloride 
 in 100 c.c. ; Saturated aqueous solution of Bismarck brown; 
 Wright's blood stain; Absolute alcohol; 95 per cent al- 
 cohol; Ether; Chloroform; Loffler's methylene blue; Gum 
 guaiac ; Tincture iodine ; Hydrogen peroxide ; Saturated 
 aqueous solution of methylene blue; Topfer's reagent (di- 
 methyl-amido-ozo-benzol .5 per cent in 80 per cent alcohol) ; 
 Gunzburg's reagent (phloroglucin 2 gms., vanillin 1 gm., 95 
 per cent alcohol 30 c.c.) ; Carbol-fuchsin (carbolic acid 5 c.c., 
 saturated alcoholic solution of fuchsin 10 c.c), and distilled 
 (74) 
 
Apparatus and Reagents Necessary for Laboratory. 75 
 
 water 100 c.c.) ;5 per cent copper sulphate solution ; Strong 
 sodium hydrate solution; 10 per cent copper sulphate solu- 
 tion; 5 per cent ammonium iron alum solution; 10 per cent 
 ammonium hydrate solution; Saturated potassium oxalate 
 solution; 10 per cent aqueous solution ferric chloride; Ani- 
 line oil; Saturated alcoholic solution of gentian violet; 5 
 per cent aqueous solution of carbolic acid; Crystals of so- 
 dium iodide; Infusorial earth; 4 per cent solution of glacial 
 acetic acid tinged with little gentian violet; 10 per cent 
 butyric acid solution in normal saline ; Normal sodium 
 hydroxide solution; 10 per cent potassium f errocyanide ; 
 Red litmus paper; Blue litmus paper. 
 
 FehUng's Solution. — Dissolve 34.64 gms. of pure copper 
 sulphate in water and make up to 500 c.c. Dissolve 173 gms. 
 of E-ochelle salts and 125 gms. of sodium hydrate each in 200 
 c.c. of water. Mix and make also to 500 c.c. Keep copper 
 solution and alkaline solution in two separate bottles. 
 
 Sulphamlic Acid. — Make a saturated solution of sulpha- 
 nilic acid in a 5 per cent hydrochloric acid solution. This 
 is for the Diazo reaction. 
 
 Bromine Solution (For Urea). — Bromine 30 c.c, potas- 
 sium bromide 30 gms., and distilled water 240 c.c. 
 
 Sodium Hydrate Solution {For Urea). — Sodium hydrate 
 10 gms., distilled water 250 c.c. 
 
 Hayem's Solution. — Mercuric chloride 0.5 gms., sodium 
 chloride 1 gm., sodium sulphate 5 gms., distilled water 200 c.c. 
 
 Gram's Iodine Solution. — Iodine 1.0 gm., potassium iodide 
 2.0 gms., distilled water 800 c.c. 
 
 Eshach's Reagent. — Picric acid 1.0 gm., Citric acid 2 gms., 
 water 100 c.c, 
 
 Phenylhydrazine Acetate Solution. — 20 per cent aqueous 
 solution of sodium acetate 25 c.c, 10 per cent aqueous solu- 
 tion of phenylhydrazine hydrochloride 25 c.c. Mix. 
 
 Nylander's Reagent. — Bismuth subnitrate gms. 2, Rochelle 
 salts 4 gms., 8 per cent sodium hydrate solution 100 c.c 
 
 Standard Silver Nitrate Solution. — 7.27 gms. to 250 c.c of 
 distilled water. 1 c.c. of this equals 10 M. gms. of sodium 
 chloride. 
 
76 Diagnostic Methods. 
 
 Standard Ammonium Sulphocyanat Solution. — 3.25 gms. 
 to 250 c.c. distilled water. 1 c.c. of this equals 1 c.c. of the 
 silver nitrate solution. 
 
 Tsuchiya's Reagent. — Phosphotungstic acid 1.5 gm., con- 
 centrated hydrochloric acid 5.0 c.c, 95 per cent alcohol 95 c.c. 
 
 Acid Alcohol.' — 1^/2 c. c. of concentrated hydrochloric acid, 
 981/2 c.c. of 95 per cent alcohol. 
 
 Rudisch Solution {For Quantitative Glucose). — 200 c.c. of 
 50 per cent aqueous solution of potassium sulphocyanate, 
 and 150 c.c. of a mixture of equal parts of Fehling's copper 
 sulphate and alkaline solutions. 
 
INDEX 
 
 A 
 
 AcHTLiA gastrica, 44 
 
 Apparatus necessary for physician's laboratory, 74 
 
 B 
 
 Blood, 45-53 
 culture, 51 
 
 examination of fresh, 45 
 haemoglobin, 45 
 estimation of, 45 
 
 by Sahli hsemometer, 45 
 by Talquist scale of colors, 45 
 color index, 46 
 Widal's serum reaction, 50 
 Blood changes in: 
 
 acute lymphatic leukemia, 52 
 chlorosis, 53 
 
 chronic lymphatic leukemia, 53 
 pernicious anemia, 52 
 splenomegaly or splenic anemia, 53 
 spleno-myelogenous leukemia, 53 
 Blood counting, 46 
 
 apparatus for, cleaning of, 49 
 chambers for, 47 
 red corpuscles, 48 
 white corpuscles, 49 
 Blood smear, making of, 46 
 method of staining, 49 
 
 C 
 
 Complement fixation test for gonorrhea, 72-73 
 Chemical reagents needed for laboratory, 74-76 
 
78 Index. 
 
 Examination of: 
 alimentary canal, 13 
 cardiovascular system, 14 
 cranial nerves, 15 
 ears, 18 
 eyes, 17 
 
 elastic fibers, 22 
 larynx, 18 
 
 locomotor system, 17 
 motor functions, 16 
 nervous system, 15 
 nose, 18 
 reflexes, 17 
 
 respiratory system, 14 
 sensory functions, 16 
 sputum, 19 
 urine, 25 
 
 Gastric cancer, 43 
 Gastric contents, 38-44 
 chemical examination for: 
 
 blood, 41 
 
 combined hydrochloric acid, 39 
 
 free acids, 39 
 
 free hydrochloric acid, 39 
 
 organic acids, 40 
 
 pepsin, 40 
 
 rennin, 40 
 in disease, 43 
 
 microscopical examination, 43 
 physical examination, 38 
 
 color, 39 
 
 mucous, 39 
 
 odor, 39 
 
 quantity, 38 
 quantitative examination for: 
 
 combined hydrochloric acid, 42 
 ■ free hydrochloric acid, 41 
 
 total acidity, 42 
 test meal, 38 
 
Index. 79 
 
 Gastric neurosis, 44 
 
 ulcer, 43 
 Gastritis, chronic, 44 
 Gram's stain, 22 
 
 H 
 
 History taking, outline for, 9-12 
 History, family, 9 
 past, 10 
 personal, 9 
 of present illness, 10 
 alimentary canal, 10 
 blood, 12 
 
 bones and joints, 12 
 cardiovascular system, 11 
 child, 12 
 kidneys, 11 
 liver, 11 
 
 nervous system, 12 
 respiratory system, 11 
 
 IntestiA'AL contents, 58-63 
 chemical examination of, 60 
 
 bile (hydro-bilirubin), 60 
 
 blood (occult), 60 
 macroscopic examination of, 58 
 
 blood, 59 
 
 color, 58 
 
 consistency, 59 
 
 curds, 59 
 
 frequency, 58 
 
 mucus, 59 
 
 odor, 59 
 
 pus, 59 
 
 quantity, 58 
 microscopical examination of, 61 
 
 bacteria, 61 
 
 blood cells, 61 
 
 epithelial cells, 61 
 
 food particles, 61 
 
80 Index. 
 
 ova of intestinal parasites, 62 
 pus cells, 61 
 stools, examination of, 58 
 Intestinal parasites recognized by the parasite itself, portions of the 
 parasite, or larvK, 63 
 
 S 
 
 Serous fluids, 54-57 
 
 bacteria in, 55 
 
 chemical examination, 54 
 
 cytodiagnosis,54 
 
 lumbar puncture, technique for, 56 
 
 Noguchi's butyric acid test, 56 
 
 physical examination, 54 
 
 total cell count of, 55 
 Sputum, 19-24 
 
 bacillus tuberculosis, staining of, 21 
 
 color of, 20 
 
 elastic fibers, examination for, 22 
 
 examination of, 19 
 
 hemorrhagic, 20 
 
 macroscopic examination, 19 
 
 microscopic examination, 20 
 
 mucous or viscid, 19 
 
 mucopurulent, 19 
 
 nummular, 20 
 
 odor, 19 
 
 origin, 19 
 
 pneumococcus, staining of, 21 
 
 purulent, 19 
 
 quantity, 19 
 
 serous, 19 
 
 tenacious, 20 
 
 Sputum in bronchiectasis, 24 
 in bronchitis, 24 
 in bronchial asthma, 24 
 in pneumonia, 23 
 in tuberculosis, 23 
 
 TuBERcuLix diagnosis, 64-66 
 Koch's subcutaneous method, 64 
 contra-indications, 64 
 
Index. 81 
 
 diagnostic value, 65 
 
 indications for use of, 64 
 Moro ointment reaction, 64 
 Ophtlialmo reaction of Calmette, 66 
 
 contra-indications, 66 
 
 diagnostic value, 66 
 Von Pirquet cutaneous reaction, 65 
 
 diagnostic value, 65 
 
 interpretation of, 65 
 
 U 
 
 Urixe. 25-37 
 
 acute diffuse nephritis, 35 
 arteriosclerotic kidney, 37 
 bacillus tuberculosis in, examination for, 34 
 chemical examination: 
 
 acetic acid and ferrocyanide test for albumen, 26 
 
 acetone, 29 
 
 albumen, tests for, 26 
 
 albumose, 27 
 
 beta-oxybutyric, 29 
 
 bile, 27 
 
 diacetic acid, 29 
 
 dlazo substances, 29 
 
 indican, 28 
 
 nucleo-albumen, 27 
 
 haemoglobin, 27 
 
 serum-albumen, 26 
 
 serum-globulin, 27 
 
 sugar, 28 
 chronic diffuse nephritis, 35 
 chronic interstitial nephritis, 36 
 preservation of, 25 
 quantitative examination of abnormal constituents, 2,1 
 
 albumen, 31 
 
 Indican, 32 
 
 sugar, 33 
 quantitative examination of normal constituents, 30 
 
 chlorides, 30 
 
 total acidity, 31 
 
 total solids, 31 
 
 urea, 30 
 
82 Index. 
 
 renal tuberculosis, 36 
 
 sediment in, microscopical examination of, 
 
 turbidity of, 25 
 
 W 
 
 Wasserman>' reaction, 67-71 
 amboceptor, preparation, 67 
 
 standardization, 67 
 antigen, preparation, 68 
 
 standardization, 68 
 complement, obtaining, 69 
 
 preparation, 69 
 diluting fluid, 69 
 patient's sera for test, 69 
 sheep's red blood cells, 69 
 Wassermann test, technique of, 70 
 interpretation, 71 
 
The Mosby Company's New Books on Diagnosis 
 
 LABORATORY METHODS 
 
 With Special Reference to the Needs of the General Practitioner 
 
 By B. G. R. WILLIAMS, M. D., 
 
 Member of Illinois State Medical Society, American Medical Associatioiij, Etc. 
 
 Assisted by E. G. C. WILLIAMS, M. D., 
 
 Formerb' Pathologist of Northern Michigan Hospital for the Insane, 
 Traverse City, Michigan, Etc. 
 
 With an Introduction by 
 
 VICTOR C. VAUGHAN, M. D., LL.D., 
 
 Professor nf Hygiene and Physiological Chemistry and Dean of the Department of 
 
 Medicine and Surgery, I'niversity of Michigan ; President-Elect 
 
 of the American Medical Association. 
 
 SECOND EDITION, REVISED AND REWRITTEN. 
 
 Octavo, 2.50 pages, with .50 engravings. Cloth, .$2.50 
 
 CONTENTS 
 
 Chapter 
 
 I. General Considerations. 
 II. The Sputum, 
 in. Searching for Germs. 
 IV. Vascular Dramas. 
 V. Chemistry and Biology of the 
 
 Gastric Juice. 
 VI. Essence of Tissue Diagnosis. 
 VII. Detection of the Common Poi- 
 sons. 
 VIII. Exudates in Brief. 
 IX. Diazo Versus Widal. 
 X. The Urine in Disease. 
 
 Chapter 
 
 XI. Millv and Its Home Modifica- 
 tions. 
 
 XII. Some Simple Water Analyses. 
 
 XIII. Every-Day Stool Tests. 
 
 XIV. Technic of the Private Post- 
 
 Mortem. 
 
 XV. To Find the Treponema in Six 
 Minutes. 
 
 XVI. Laboratory Prophylaxis. 
 
 XVII. Indications for Laboratory Aids. 
 
 XVIII. Tables and Miscellaneous. 
 
 FROM REVIEWS 
 
 This book may he freely commended to those who may desire a working guide to 
 the more usual laboratory methods. The stj'Ie is clear and concise, and the general 
 makeup of the book is excellent. — .Journal of the American Medical Association. 
 
 General practitioners are under an everlasting debt of gratitude to the Williamses 
 for their textbook. Any publication which lightens the burdens of these physicians 
 and points out a way to bettering their work is bound of necessity to succeed. — 
 Maryland Medical .Tournal. 
 
 It has been the aim of the authors of this admirable book to simplify methods 
 both as to apparatus and technic, and we can testify that they have succeeded most 
 admirably in their every effort. Every general practitioner should procure a copy of 
 this book and study it carefully, and it will show that many of the comparatively 
 simple cases that are usually sent to distant cities for expert examination may be 
 made with more satisfactory results by the practitioner at home. — The Medical Sum- 
 mary. 
 
The Mosby Company' s Neiv Books on Diagnosis 
 
 TUBERCULIN 
 
 In Diagnosis and Treatment 
 
 By FRANCIS MARION POTTENGER, A. M., M. D., LL.D., 
 
 Medical Director of the Pottenger Sanatorium for Diseases of the Lungs and Throat, 
 Monrovia , California . 
 
 Octavo, 250 pages, with 
 
 engravings and 1 color plate. 
 
 Price, Cloth, $2.50. 
 
 Tuberculin is a great therapeutic remedy. Since its first introduction b.v Robert 
 Koch it has proved of inestimable value in the hands of the skillful phj'sician. 
 The occasional bad results that have attended its use have been due more to 
 faulty technique than to the remedy. Doctor Pottenger has authority to speak on 
 this subject. This book is the experience he has gained by treating more than two 
 thousand cases in private sanitarium practice. 
 
 CONTENTS 
 
 Chanter 
 
 I. Importance of the Tuberculin 
 Test in tlie Early Diagnosis 
 of Tuberculosis. 
 
 II. Subcutaneous Tube r culin 
 Test. 
 
 III. Cutaneous Tuberculin Test. 
 
 IV. Percutaneous Tuber culin 
 
 Test. 
 
 V. Conjunctival Tuberculin Test. 
 
 VI. Tuberculin in the Treatment 
 of Tuberculosis. 
 
 VII. Hypersensitiveness. 
 
 Chapter 
 VIII. 
 
 X. 
 XI. 
 XII. 
 
 Appendix. 
 
 Certain Conditions Which 
 Have Made the Adoption of 
 Tuberculin as a Diagnostic 
 and Therapeutic Measure 
 Difficult. 
 
 Evidences of the Therapeu- 
 tic Value of Tuberculin. 
 
 Fever in its Relatiousliip to 
 Tuberculosis. 
 
 Temperature Curve in Tuber- 
 culosis. 
 
 Technic of Administering 
 
 Tuberculin. 
 Koch's Announcement of the 
 
 Discovery of Tuberculin/. 
 
 FROM REVIEWS 
 
 This book by Pottenger, who has long been recognized as an authority on every- 
 thing pertaining to pulmonary tuberculosis, contains about everything worth knowing 
 at the present time on the use of tuberculin in both diagnosis and treatment. It is 
 a book of great value not only to the specialist, but also to the general practitioner. 
 — .lournal of the Michigan State Medical Association. 
 
 We have enjoyed reading this work. Dr. Pottenger has the reputation of being 
 exceptionally thorough in his diagnostic work and we are given the benefit of this in 
 the book. The author makes it plain that the use of tuberculin for diagnostic pur- 
 poses is corroborative only, that to in any measure neglect the history and physical 
 findings invites failure. We heartily recommend this book to the attention of gen- 
 eral practitioners. — Journal of the Iowa State Medical Association. 
 
The Mosby Company's New Books on Diagnosis 
 
 THE WASSERMANN REACTION 
 
 Its Technic and Practical Application in the Diagnosis of Syphilis 
 
 By JOHN W. MARCHILDON, B. S., M. D., 
 
 Assistant Professor of Bacteriology, St. Louis rniversity Medical School, 
 St. Louis. 
 
 105 pages, with 11 illustrations and 1 colored frontispiece. 
 Price, Cloth, $1.50. 
 
 CONTENTS 
 
 Chapter 
 
 I. ^Materials Required for Making 
 tlie Wassermann Reaction. 
 
 II. The Preparation of the Hem- 
 olytic Amboceptor or Hemoly- 
 sin. 
 
 III. The Preparation of Complement. 
 
 IV. The Preparation of Red Blood 
 
 Corpuscles. 
 
 y. The Preparation of Serum from 
 the Patient. 
 
 \J. The Preparation of the Antigen. 
 
 Chapter 
 
 VII. To Obtain the Dosage of an Ex- 
 tract. 
 VIII. The Method of Making a Was- 
 sermann Reaction. 
 IX. The Modification of the Wasser- 
 mann Reaction. 
 X. The Wassermann Reaction in 
 
 Syphilis. 
 XI. The Wassermann Reaction in Dis- 
 eases other than Syphilis. 
 XII. The Influence of Anti-Sypilitic 
 Treatment on the Wassermann 
 Reaction. 
 
 FROM REVIEWS 
 
 We can commend this excellent little work to those who wish to become more 
 independent of the larger laboratories and to place themselves in a position better to 
 understand and perform this most important diagnostic test. — Journal American 
 iledical Association. 
 
 This volume should be on the shelves of every physician. — Interstate Medical 
 .Tonrnal. 
 
 We commend the work to those of our readers interested (and what physician is 
 not) in the accurate diagnosis of syphilis. — The American Practitioner. 
 
 This little volume, big enough, sets forth In clear terms the technic of the Wasser- 
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 This primer of the Wassermann reaction can be recommended as a very clear and 
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The Moshy Company's New Books on Diagnosis 
 
 VACCINE AND SERUM THERAPY 
 
 Including also a Study of Infections, Theories of Immunity, Specific 
 Diagnosis, and Chemotherapy 
 
 By EDWIN HENRY SCHORER, 
 
 B. S. (University of Wisconsin), il. D. (Jolius Hopkins University), 
 Dr. P. H. (Harvard Univeristy). 
 
 Formerly Assistant Thomas Wilson Sanitarium for Children, Mt. Wilson, Maryland; 
 Asst. Rockefeller Institute for ^Medical Research, Xew York City ; and at one 
 time Member of the Faculty of the University of Missouri, of the 
 University of Kansas, and of the Department of Preventive 
 ^Medicine and Hygiene of Harvard Univer- 
 sity, Boston. 
 
 Octavo, 2.50 pages, with IS engravinga and a colored plate. 
 
 Price, Cloth, $3 00. 
 
 SECOND REVISED EDITION. 
 
 
 
 CONTENTS 
 
 Chapter 
 
 
 Chapt 
 
 I. 
 
 Infections. 
 
 
 
 ir. 
 
 Immunity. 
 
 
 
 III. 
 
 Specific Diagnosis. 
 
 
 
 IV. 
 
 Specific Therapy. 
 
 . 
 
 Appen 
 
 Specific Diagnosis, Treat- 
 ment and Prophylaxis In 
 the Different Infections. 
 
 Syphilis and Malaria. 
 
 FROM REVIEWS 
 
 It contains all that is necessary for physicians to know about this new and fasci- 
 nating method of treatment. The text is well done and the illustrations are adequate. 
 Doctor Schorer has had a large and varied experience and is the master of the 
 technique of the laboratory. — The Canadian Medical Association Journal. 
 
 The whole subject has been treated in a very practical and comprehensive manner, 
 and we heartily recommend the book to all who may be interested in the subject. — 
 Journal of the Indiana Medical Association 
 
 This revised second edition will be welcomed by all interested in the treatment of 
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 It is a book which merits careful study in order that such a valuable adjunct as 
 vaccine therapy may not be either over-rated or under-rated. — Journal of the Iowa 
 State Medical Society. 
 
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