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Contributed Articles

THE DIAGNOSTIC UTILITY OF BLOOD EXAMINATIONS*

B. F. Gillmor, M. D., Creston, Iowa.

NSTEAD of reviewing systematically the subject of "The Diagnostic Utility of Blood Examinations, "I shall turn to the laboratory records and discuss the points of interest that come to mind as the cards and cases present themselves in alphabetic review.

As in the treatment of disease much unavailing labor must be outlaid in the pursuit of satisfactory results, so in the making of diagnoses the doctor must find his quittance for the hundreds in the rewards of the single instance. However, in glancing over the records, I have been surprised at the number of cases in which the blood examination has proven, in one fashion or another, of service. Even in the instances in which it was valueless as a diagnostic measure, the very contradictions implied are full of interest, and, almost without exception, the examination had repaid the examiner for his pains.

As many cases, of all sorts, as I have time for I shall present. In the hasty review, some of my hearers may be struck by the apparent worthlessness of the examination in certain instances. Of course, we are all looking for exact means, and are all shy of hard labor and exertion devoid of immediate recompense, and it is easy to imagine the doctor who would be indifferent to the fine-haired methods of the microscopist or chemist, but it is hard to conceive of the patient who would not desire careful consideration of his case and the focusing upon it of all the light at the command of our profession, regardless of the time and labor required.

14 years of age.

The first card that comes to hand is that of Inez B., She has enlarged cervical lymphatic glands, a rapid heart, carries a temperature hovering around the 100 deg. mark, complains of weakness, periodic anorexia and insomnia. The first examination of the urine revealed no albumen or casts, but the total quantity for 24 hours was but eight ounces. The urine was highly alkaline and full of triple phosphate crystals, suggesting retention. The patient was catheterized and no urine found retained in the bladder. Serial examinations revealed a periodic decrease in the urinary volume; yet, at the periods of greatest renal activ

Read before the Southwestern Iowa Medical Association.

ity the total solids excreted were always deficient. No albumen was found and a diagnosis of nephritis could not be made on the strength of the few hyaline casts discoverable. Physical examination revealed areas of impaired resonance over the chest together with the presence of rales, and a harsh respiratory sound. The heart and abdominal viscera were normal. The sputum was examined and no tubercle bacilli found.

In view of the general symptom complex and the presence of enlarged glands it was necessary, in the making of a diagnosis, to exclude lymphatic leukemia or other blood disease. The blood examination revealed 95 per ecnt hemoglobin, 5,000,000 reds and 15,000 whites-certainly excluding leukemia. The age of the patient, the fact that she had taken dinner but three hours before and the small number of leucocytes found rendered a differential count unnecessary.

Although no tubercle bacilli were found, a diagnosis of tuberculosis was made and the presence of intra-thoracic lesions demonstrated with the X-ray. The glandular enlargement was dependent, undoubtedly, upon tu. bercular processes. In this case the blood examination, though of negative value, was of unquestionable weight in the confirmation of a diagnosis. A year after this examination was made patient died of tuberculosis.

Three examinations are recorded on the card of Mrs. B. At the time of the first examination she was suffering-to save words-with chronic malarial cachexia. This was the diagnosis of Dr. Rawls, and the subsequent career of the patient fairly well confirms his opinion. The first examination revealed no plasmodia milariae; there was 65 per cent hemoglobin, 3,500,000 reds and 8,000 whites-nothing contradictory, surely to the diagnosis already made, and nothing directly suggestive of other disease.

The patient was placed on appropriate treatment, which was of undoubted efficacy, thought the impression made by medication on the progress of the disease was hardly appreciable at that time.

She complained of a great deal of pain through the lower part of the chest, which was periodical in character and so severe as to keep the patient awake nights and, incidentally and on account of her screaming, the rest of the household. Gradually the pain localized itself in the right side, becoming suggestive of biliary obstruction or renal calculus. At this time, the sufferings of the patient were most agonizing and acute; her screams could be heard by the nearest neighbor, some hundreds of yards away. She must of necessity sit bent over in a chair, hour after hour, night after night, tortured and agonized by pain in her side. The patient had almost no desire for food, and the small amount of nourishment she retained was certainly not sufficient to maintain life. Her condition was very grave and we were much concerned about her.

The next examination of the blood revealed a slight increase in the number of erythrocytes; but the examination was so unsatisfactory, owing to the fact that the husband seated himself in the midst of our apparatus, that we feared to place dependence in its findings.

The probabilities of there being a renal or biliary calculus were becoming very strong, and the advisability of the removal of the patient to the hospital for closer observation and, perhaps, a skiagraph were urged

upon the patient and her husband. On the advise of Dr. Rawls, the patieni was taken to the hospital, where an attempt to radiograph the painful side was made. The attempt, however, was unsuccessful, for, accidentally tapping a piece of furniture with my foot, I precipitated a paroxysm of pain, the writhing of the patient rendering a skiagraph impossible.

At this juncture, the doctor and I exchanged significant glancesAh! there was the old familiar ring to this! Heretofore we had repeatedly disabused our minds of uncharitable thoughts, but from that time on, "trifles light as air" became "proof as strong as holy writ."

The sufferings of the patient were truly frightful; night after night, she converted the house into another Bedlam. If this was simulation, it was such rare acting as would do credit to a Garrick. As would be the case with every physician, we were loath to make a diagnosis of malingering, while the patient might really be suffering with a serious disease. Clinically the case was rapidly progressing, but we could make out nothing objectively confirmatory of a diagnosis of either renal calculus, gallstone or malignant liver and serial urinary examinations, although revealing some pathology, did nothing in the way of clearing up the diagnosis. The pain alone, if real, would have been the undoing of any human frame.

A blood examination now revealed an increase of 5 per cent in hemoglobin and 30,000 reds over the first one, some 26 days before. This made it very improbable that even the pain existed.

The doctors now lost interest and the patient, seeking to revive her lost prestige, artfully shifted from the stage of her late histrionic triumph to the other side. But the fickle gods had turned! Dr. Rawls then curtained himself in heart-to-heart communion with the sufferer. The exact nature of the conference I have never learned, but the next day the patient was sufficiently strengthened in body and fortified in spirit to take up her couch and return to the cool brooks and whispering willows of her country home. Two weeks after, she was "cured" by a magnetic healer." Two weeks was certainly the least respectable time in which a real invalid. could be expected to get well.

I have no doubt the woman was really ill, in the beginning, suffering, perhaps with intercostal neuralgia, but, plainly, the case "had run into something not exactly in our line. This case illustrates once more the negative value of blood examinations and the availabiilty of serial observations in cases where a single count would be valueless.

In the case of Bogar we find a man afflicted with a firm, rather painless swelling in about the middle of each forearm. He gives the history of injury to the arms while shoveling. The growths have steadily increased in size. They are tender, slightly, on deep pressure, and in this way spots somewhat softer than the rest may be made out. The skin is not involved, there is no glandular enlargement and the general health of the patient seems unaffected.

He gives no history of lues. He is a man of intelligence, and when the case was explained to him candidly, he searched his memory for all that might be construed as a syphilitic taint. Here was the lone and mel