CLINICAL PATHOLOGY AND GENERAL PRACTICE BY
H.
Area
J. GIBSON, M.D., D.P.H.
Pathologist,
Bath Clinical Area
significant medical trends in England today is the movement toWar(je the most at home of many patients formerly regarded Treathospital nientVreatrnent ^ vitamin be carried out at home the as
cases.
or by anticoagulant can antibiotic, by by doctor as efficiently as in hospital in those cases which do not require Y. skilled and f nyysinS or 24-hour supervision. The saving of expense to the State is obvious far ^ 6 ls reason the change is part of current policy of the Ministry of Health. How of (j tendency will go depends on the progress of research into the cause and cure diseases, neoplasms and rheumatism. In future the ^?sPit e1nerat^ve cardiovascular maY become increasingly places for investigation and for initiation and stably ^Varc^s of a treatment regime which can be continued by the family doctor at ^lone Process of transition with disappearance of hospital beds is seen at present in va for infectious diseases, venereal diseases and tuberculosis. It need degrees Vdlv K 6 Sa*d that this trend towards domiciliary treatment is welcomed by all who We at heart and most by the general practitioner general practice ^Uself6 YV?^arefull access to special departments his status at once becomes that of a scieriti^'? Physician able to practise the medicine he learned in his teaching hospital. An Pre~recluisite for the management of cases at home is that full laboratory ^cilitiggSent^ sh?uld be available. Initial diagnosis may then be made with certainty, fteat^68 be guided by laboratory findings, and the progress of the case followed an Way ^ the use of appropriate laboratory tests. Accurate prognosis and aSSessmJeCtlVe ent of cure can be placed on a safe footing.
keen
f
'
?
tu
*
HOW TO USE THE SERVICE
^a?er explains
how practitioner can make best use of the services of the day-to-day running of his practice. The service is now fully available and most teaching centres, and all that is required, is that the doctor S^0Uld k0vlncial able to take specimens and deliver them without delay to the nearest laboraS. en this small effort is unnecessary with ambulant patients who can attend an appointment must be made as certain times are set aside ^hichat?ry, For them cases can be seen. Patients arriving at other times may have to ^ait, 0r Petitioners' important, there may be delay in examining specimens with c?ilseq what is more of 1!laccuracy results. Where the case is not an urgent one, many practi|(l0Hers the laboratory "Request Form" stating on it ^ieaSe ^ convenient to complete and it to the laboratory secretary who can then send appointment" r?1^6 Us ha ^te directly with the patient and make an appointment for his attendance. k rePortPosted the request form the practitioner need only await the arrival of
!aborat ^
a
the
all
'
in the arrangements made for general practitioners' work and l^e first at?r^e? differ ascertain the of the nearest most conveniently situated ak?rat0rSteP t?t? rnake contact with the and his staff. Details *s
name
S theri\and personal discussed of times and methods. ained p a*d hints given which will smooth *Slo
or
pathologist Outfits for specimen
collection may be difficulties which may arise. -S ?ften have a wide field of subsidiary laboratories and other hospitals to and it ls ePartm s-Weh to make the acquaintance of chief and senior technicians in the various These men are highly expert in all branches of their work and are able V ?'*??>? No. ,66. ,o9
(]1Slt
out any
110
DR. H. J. GIBSON
hltf
?1
give practical advice on both technical and theoretical points. They are aval at any time during laboratory hours when the medical staff may be inaccessibleIt is very desirable that each practitioner should deal always with the same la t ^ tory even if more than one is conveniently situated. Records are kept of each / and reference to them by the pathologist making the report may be most help a num To over have such records scattered a of elucidating problem diagnosis. laboratories is as detrimental to the patient's interests as would be his having 1 more family doctors. The pathological services are already widely used by general practitioners. I*1 -0ji where these services have been freely offered since the appointed day, the pr?P all ^ of G.P. work is steadily rising and now accounts for 12 per cent of the total, jjy general practitioners used it as enthusiastically as the few who co-operate rt\?st js with the laboratory the proportion would be far higher. Work from practitio11 0f welcomed by all pathologists who find it most interesting. After nearly nine y se to
.
the National Health Service the author has never encountered any abuse of this j5 The investigations requested are relevant, usually simple and the "specific probie usually one in which the laboratory can help. In many cases clues obtained ^ simple test can be followed up on the material sent and a definite diagnosis out further reference to the practitioner. We have rarely found general practi in employing the regrettable "drag-net" technique in which a mass of unrelated ^ to diagnosis may emerge. a gations are ordered in the hope that some clue 0[ "drag-nets" elsewhere the most likely finding is an "old boot" in the form of and misleading minor abnormality. Pathological requests should always arise the clinical study of the patient and one line of investigation should be exhausted another is commenced. ,
.
.
SOME PITFALLS jt To those who may be unfamiliar with the interpretation of laboratory fin a ot cannot be too strongly emphasized that no diagnosis should be founded on jgg Exai^F' if is at with it variance the overall clinical result ajjr picture. pathological this pitfall are legion. Thus a very high "blood urea" may be found in a blood c? ing Wintrobe's ammonium oxalate mixture as anticoagulant if the common NeS, ?? tion method is used. Alarming blood-sugar values have been found in ( c[ with a syringe recently used for injecting glucose solution. Consternation was a P many years ago when a patient in a rheumatic-diseases hospital, who was r one of the sterner religious sects, was found to have a positive Wassermann ^ jj& Reviewing his case in the light of recent knowledge, it is almost certain disseminated lupus erythematosus in which a biological false positive reaction is a recognized finding, as it is of course in some cases of glandular *e atypical virus pneumonitis. In all cases of this kind when doubt exists, the tes be repeated and the findings discussed with the pathologist. Another common source of error arises from not approaching the investig3 >jofl a problem case in a systematic way. It is better to begin with a Blood Sediifle jjlr Rate, blood count and urine. The more spectacular tests can come later. ItlS gjjnp 0 ing how often a rare and puzzling syndrome resolves itself into an attack is examined! Clotted blood was sent when urine for Brucella the pyelitis test from a farmer with unexplained fever; it was positive, and much valuable lost before the case was reinvestigated and found to be one of generalized tu a The Brucella antibodies were presumably the result of infection j his work in infected cattle. during handling the The clinician should not expect all laboratory results to agree fully with & patterns associated with specific diseases. Many factors modify the findings especially previous treatment. For this reason a note of treatment given shou ^ be made on the request form if it is likely to modify the laboratory findings l*1 It is common now to find a purulent cerebrospinal fluid to be sterile on cu _
gjj,gle
^a^Sve .
^
agg^.^e
previously
aCquife
clasS'.C(? ^
CLINICAL PATHOLOGY AND GENERAL
?f
PRACTICE
III
klood cultures do exclude active infective endocarditis. Carcinoma th^VCStornac^ usually increases the B.S.R. but normal result may be found in scirnot
an
a
rVis
n?n-ulcerating
and also in some other evidence of liver
cases
pces e.nce of jaundice or rate Va^d but a normal
giverJS
excludes
rate
cases
where the liver is involved.
In
damage the B.S.R. is suspect. A rapid nothing. Many similar examples could be
As' v,
killing diseases are being mastered, others, once rarities, are taking their ^ is necessary, however, to preserve a sense of proportion. Polyarteritis Hod a disseminated lupus erythematosus are undoubtedly more common than fnen On the request form full Christian names should be[ errors of identification. and date of birth is a better identification feature than age alone. The date and ti ^ a taking the specimen will show the pathologist what tests are possible and whatne ance must be made for deterioration. Space is always provided for clinical ^ A long essay on the case is not called for. A few well-chosen words will indica ^ duration of illness, the salient clinical features, any tentative diagnosis clinical1; gested and any specific treatment given. Thus "3/12 loss of weight, brile? Ca. stomach? Anaemia. Imferon given" provides the pathologist with a ^ j ground against which he can interpret his findings and possibly suggest or car further tests. Without these few words he is working in the dark. The assi given to the practitioner by a pathological report is often in proportion to the in tion which he gives the laboratory. Time spent on the request form is well spe
^
dyspeps13^?
NOTES ON MORE COMMON
METHODS AND APPLICATIONS OF CLINICAL
Anaemia
PATHOLOgY 10f
.
Where the symptoms point to anaemia, leukaemia or other blood disease a 0d at least 3 ml. of well-shaken unclotted blood should be sent together with a drie ^ film. The drop of blood in the needle may be used for making this film. For r,^ specimens the importance of a well-made film cannot be practitioner should secure a supply of microscopic slides and practise until he can en a really good film. This must be quite dry before it is wrapped in paper and with the bottle. The name may be written in ink over the thick end of the film. A well-made film alone can often be far more informative than a bottle 0 .
over-emphasized. ^
^
blood. tion If the blood shows an iron-deficiency anaemia of low colour index the o^eS. in its cause arises. A B.S.R. estimation can be very helpful, a definite increase that there is some underlying disease process such as infection or neoplasm to ^ anaemia is secondary. A leucocytosis or leucopenia may point to infection, or aD Jfit white cells to leukaemia. In every case of severe unexplained iron-deficiency aan*e x *three a faeces specimen should be sent for occult blood test before and after a or on a white diet. Blood loss is period by far the commonest cause of this type and treatment must be directed to the bleeding point rather than the blood. jui! up examinations only call for haemoglobin estimation at intervals of 2-4 wee blood counts are unnecessary when a diagnosis has been established. t0 If the anaemia is of macrocytic type with high colour index a complete cannot be made on peripheral blood examination alone. A test meal is req determine whether there is achlorhydria and sternal marrow examination is able .(jo11 sary. For the general practitioner a Diagnex (Squibb) tubeless test meal is whether free hydrochloric acid is present or absent. It involves the oral s of the contents of two small cachets and the collection of three timed urine or Estimation of quinine in the urine indicates whether free acid is present Full instructions are given with each outfit. A complete diagnosis requires in addition sternal puncture and a faecal fat ...
^jclj
^jred
a|s togfr0,v a^.mingaInp'e5
CLINICAL
test,
re
?
PATHOLOGY AND GENERAL PRACTICE
113
.
patient to go into hospital and in presence of typical of pernicious anaemia including achlorhydria pictures and Bi2 rjnal B.S.R. then many practitioners are satisfied to give a trial dose of Vitamin ^ave t^ie blood examined for a reticulocyte count in 5 to 10 days. If this resPo Se ls satisfactory, treatment may be continued with confidence. If the anaemia d?es full investigation in hospital is necessary, but by then the vitamin respond, givennot have modified marrow picture. So it is clearly best to have the full invest-may made before thetreatment is given. On no account should the therapeutic test Aatl?* any ma^e because in true Addison's anaemia (true P.A.) folic acid precnv ates ac^ Out sf' devastating nervous involvement. It is possible but not desirable to carry Preljm"1" Puncture as an out-patient procedure. It alarms the nervous patient and
clijjj
ls
.
an? {fy within three hours of taking. In view of the value of the test a number of a ^ practitioners remote from the laboratory have found it worth while to acquire rack and a number of Westergren tubes. These are obtainable commercially acute
diseases
may be raised.
fibrinogen
It is sometimes stated that
'
c?.^ple
laboratory supply The procedure
houses. is simple.
cjtr^te
bottle of 3-8 per cent, sodium solution. Fill the pipette to the 150 mm. mark (i.e. one quarter full) with^ ^ solution and place it in a small test-tube. To this add one pipette full to the with blood from the specimen before it is sent to the laboratory for the count. ^ and citrate are mixed and the pipette is then filled with diluted blood to the rt13 gJ1js kit j placed vertically in the stand. A simple timing device such as used in the set to ring after one hour. If the doctor himself cannot be present to read it, the ^ level after one hour may be exactly marked by sticking a piece of adhesive papef e^t inte even a task is the of or which well within tube, wife, secretary competence daily help, after instruction. The upper limit of normal is 15 mm. in 1 hour. The other extreme is repreS by myelomatosis where rates of over 100 mm. in one half hoar are common. Have at hand
a
u^jo0(i .
^ed
Suspected Infection, Acute and Chronic In any patient with a fever of unknown origin the appropriate investigations on the differential diagnosis; this of course varies from case to case. Pfltn ^ material, sent for bacteriological examination, should include urine in eVer^jable' with swabs, faeces, vomitus, sputum, pus or serous effusions where they were The initial routine investigation may also include (1) unclotted blood for tests ful^ an count, B.S.R. and biochemical tests, (2) clotted blood for serological tests c such as the flocculation reactions which are used in hepatitis, and (3) blood ^ M The B.S.R. and the leucocyte picture may then suggest a group of infection^ be ?$. further as Paul Bunnell tests such the may investigated by serological glandular fever, cold agglutination or M.G. streptococcus test in primary yjf115 virus pneumonitis, or the Brucella agglutination tests. In the case of suspecte ^ ?^ and rickettsial infections a specimen of serum secured early in the disease Is vjfiis value as it can be compared with a second specimen taken in convalescence. serology such paired specimens are necessary in view of the great differences ^eI-elS individuals in the normal antibody titres. When blood culture is called for no substitute for an autoclaved syringe and needle in a sealed container whicl Q pi ^1. obtained from the laboratory before use. In carrying out the routine describe ?
of blood
cU^??'
desirable of which 10 ml. are added to a bottle of broth for and 5 ml. collected in a plain bottle for serum. rna{i?5lS in the needle is then used for making a blood film. If malaria is a possible a thick smear is also made on the central one-third of a further side and weM Urine from female patients must be taken by catheter if the bacteriological tion is important. In a male a mid-stream specimen passed directly into a s bottle is satisfactory. are
mixed with
anticoagulant
!LrjliZe
CLINICAL
PATHOLOGY AND GENERAL PRACTICE
115
^seases e
Ending
of albuminuria should always call for a complete examination of the and cultural examination of the deposit. If evidence of renal ^ th k Presenl a blood urea estimation should be made. Further help may be given "lood urea is combined with the urea clearance test. For this test two samples ,ne are required each representing 60 minutes' renal output. The urine and blood are sent to the laboratory and the clearance as a percentage of normal can be ed. It is essential that the bladder is empty before collection of the timed specj ns commenced and if the time intervals differ from 60 minutes the exact tiitig minutes should be stated no each bottle. The whole of the timed specimen Sent because the calculation requires the renal output in ml. per minute, which may be helpful in chronic disease are serum cholesterol estimation and reserve f?r which a clotted blood sample collected under a one-half-inch
Urin e d;s
microscopic
of*
calcfi63 ?
$h0lll'n Other lutests
%er
f
?
liquid paraffin
is
required.
by g gr^static cases, besides a urine examination valuable information may be given haemoglobin, blood urea and acid and alkaline phosphatase determinations.
whether or not there is a carcinoma with or without bone secondaries. Five Sljl8?est of E.D.T.A. (or potassium oxalate) blood are sufficient for all these tests, Byu ?
.
these
be s
o
Jn
tests
arriving
carried
out
before the
diagnosis
at a
and
patient sees the surgeon, valuable time determining suitability for surgery.
of Gly ^Sation Ending reducing Afuij6
substance in the urine calls for
Henta 5leSP.ecimen passed
the
may
cosuria
of
a
a
blood-sugar
estimation,
Ucose tolerance test is not always necessary in the first place. A single "sighting be all that is required and blood taken two hours after a good carbohydrate meal, e.g., breakfast will usually show whether the glycosuria is important.
shot"
at
same
time, examined for
sugar and acetone,
supple-
tory f ^formation given by blood sugar. One has seen a patient sent to the laboralbe fa r. ?Wose tolerance test showing clinical evidence of severe diabetes, in whom blood sugar gluCOselng ^V0llld.be ill-advised.
600 mg. per cent. In such a patient a dose of 50 g. of If the result of the single test is in any way equivocal the ?Ur glucose tolerance test should be carried out at the laboratory. Glv in pregnancy is usually physiological when it is due to milk sugar but ,SUria any 0ubt exists a single blood-sugar test as described is far more useful than a lrnen for osazone or fermentation tests which are tedious to perform and i conclusive where only a trace of reducing substance is present. was over
full
^ete J?Undice
is the presenting feature a simple series of tests may be carried out whether it is due to biliary obstruction or to infective hepatitis. Five ml. clott ^ed are olood are required and a urine specimen should also be sent. The estimations serum bilirubin and serum alkaline phosphatase with serum colloidal gold, ^he Ur^dity and thymol flocculation tests. tlve bile in the urine will show that the icterus is of hepatic or obstrucan
H.
Area
J. GIBSON, M.D., D.P.H.
Pathologist,
Bath Clinical Area
significant medical trends in England today is the movement toWar(je the most at home of many patients formerly regarded Treathospital nientVreatrnent ^ vitamin be carried out at home the as
cases.
or by anticoagulant can antibiotic, by by doctor as efficiently as in hospital in those cases which do not require Y. skilled and f nyysinS or 24-hour supervision. The saving of expense to the State is obvious far ^ 6 ls reason the change is part of current policy of the Ministry of Health. How of (j tendency will go depends on the progress of research into the cause and cure diseases, neoplasms and rheumatism. In future the ^?sPit e1nerat^ve cardiovascular maY become increasingly places for investigation and for initiation and stably ^Varc^s of a treatment regime which can be continued by the family doctor at ^lone Process of transition with disappearance of hospital beds is seen at present in va for infectious diseases, venereal diseases and tuberculosis. It need degrees Vdlv K 6 Sa*d that this trend towards domiciliary treatment is welcomed by all who We at heart and most by the general practitioner general practice ^Uself6 YV?^arefull access to special departments his status at once becomes that of a scieriti^'? Physician able to practise the medicine he learned in his teaching hospital. An Pre~recluisite for the management of cases at home is that full laboratory ^cilitiggSent^ sh?uld be available. Initial diagnosis may then be made with certainty, fteat^68 be guided by laboratory findings, and the progress of the case followed an Way ^ the use of appropriate laboratory tests. Accurate prognosis and aSSessmJeCtlVe ent of cure can be placed on a safe footing.
keen
f
'
?
tu
*
HOW TO USE THE SERVICE
^a?er explains
how practitioner can make best use of the services of the day-to-day running of his practice. The service is now fully available and most teaching centres, and all that is required, is that the doctor S^0Uld k0vlncial able to take specimens and deliver them without delay to the nearest laboraS. en this small effort is unnecessary with ambulant patients who can attend an appointment must be made as certain times are set aside ^hichat?ry, For them cases can be seen. Patients arriving at other times may have to ^ait, 0r Petitioners' important, there may be delay in examining specimens with c?ilseq what is more of 1!laccuracy results. Where the case is not an urgent one, many practi|(l0Hers the laboratory "Request Form" stating on it ^ieaSe ^ convenient to complete and it to the laboratory secretary who can then send appointment" r?1^6 Us ha ^te directly with the patient and make an appointment for his attendance. k rePortPosted the request form the practitioner need only await the arrival of
!aborat ^
a
the
all
'
in the arrangements made for general practitioners' work and l^e first at?r^e? differ ascertain the of the nearest most conveniently situated ak?rat0rSteP t?t? rnake contact with the and his staff. Details *s
name
S theri\and personal discussed of times and methods. ained p a*d hints given which will smooth *Slo
or
pathologist Outfits for specimen
collection may be difficulties which may arise. -S ?ften have a wide field of subsidiary laboratories and other hospitals to and it ls ePartm s-Weh to make the acquaintance of chief and senior technicians in the various These men are highly expert in all branches of their work and are able V ?'*??>? No. ,66. ,o9
(]1Slt
out any
110
DR. H. J. GIBSON
hltf
?1
give practical advice on both technical and theoretical points. They are aval at any time during laboratory hours when the medical staff may be inaccessibleIt is very desirable that each practitioner should deal always with the same la t ^ tory even if more than one is conveniently situated. Records are kept of each / and reference to them by the pathologist making the report may be most help a num To over have such records scattered a of elucidating problem diagnosis. laboratories is as detrimental to the patient's interests as would be his having 1 more family doctors. The pathological services are already widely used by general practitioners. I*1 -0ji where these services have been freely offered since the appointed day, the pr?P all ^ of G.P. work is steadily rising and now accounts for 12 per cent of the total, jjy general practitioners used it as enthusiastically as the few who co-operate rt\?st js with the laboratory the proportion would be far higher. Work from practitio11 0f welcomed by all pathologists who find it most interesting. After nearly nine y se to
.
the National Health Service the author has never encountered any abuse of this j5 The investigations requested are relevant, usually simple and the "specific probie usually one in which the laboratory can help. In many cases clues obtained ^ simple test can be followed up on the material sent and a definite diagnosis out further reference to the practitioner. We have rarely found general practi in employing the regrettable "drag-net" technique in which a mass of unrelated ^ to diagnosis may emerge. a gations are ordered in the hope that some clue 0[ "drag-nets" elsewhere the most likely finding is an "old boot" in the form of and misleading minor abnormality. Pathological requests should always arise the clinical study of the patient and one line of investigation should be exhausted another is commenced. ,
.
.
SOME PITFALLS jt To those who may be unfamiliar with the interpretation of laboratory fin a ot cannot be too strongly emphasized that no diagnosis should be founded on jgg Exai^F' if is at with it variance the overall clinical result ajjr picture. pathological this pitfall are legion. Thus a very high "blood urea" may be found in a blood c? ing Wintrobe's ammonium oxalate mixture as anticoagulant if the common NeS, ?? tion method is used. Alarming blood-sugar values have been found in ( c[ with a syringe recently used for injecting glucose solution. Consternation was a P many years ago when a patient in a rheumatic-diseases hospital, who was r one of the sterner religious sects, was found to have a positive Wassermann ^ jj& Reviewing his case in the light of recent knowledge, it is almost certain disseminated lupus erythematosus in which a biological false positive reaction is a recognized finding, as it is of course in some cases of glandular *e atypical virus pneumonitis. In all cases of this kind when doubt exists, the tes be repeated and the findings discussed with the pathologist. Another common source of error arises from not approaching the investig3 >jofl a problem case in a systematic way. It is better to begin with a Blood Sediifle jjlr Rate, blood count and urine. The more spectacular tests can come later. ItlS gjjnp 0 ing how often a rare and puzzling syndrome resolves itself into an attack is examined! Clotted blood was sent when urine for Brucella the pyelitis test from a farmer with unexplained fever; it was positive, and much valuable lost before the case was reinvestigated and found to be one of generalized tu a The Brucella antibodies were presumably the result of infection j his work in infected cattle. during handling the The clinician should not expect all laboratory results to agree fully with & patterns associated with specific diseases. Many factors modify the findings especially previous treatment. For this reason a note of treatment given shou ^ be made on the request form if it is likely to modify the laboratory findings l*1 It is common now to find a purulent cerebrospinal fluid to be sterile on cu _
gjj,gle
^a^Sve .
^
agg^.^e
previously
aCquife
clasS'.C(? ^
CLINICAL PATHOLOGY AND GENERAL
?f
PRACTICE
III
klood cultures do exclude active infective endocarditis. Carcinoma th^VCStornac^ usually increases the B.S.R. but normal result may be found in scirnot
an
a
rVis
n?n-ulcerating
and also in some other evidence of liver
cases
pces e.nce of jaundice or rate Va^d but a normal
giverJS
excludes
rate
cases
where the liver is involved.
In
damage the B.S.R. is suspect. A rapid nothing. Many similar examples could be
As' v,
killing diseases are being mastered, others, once rarities, are taking their ^ is necessary, however, to preserve a sense of proportion. Polyarteritis Hod a disseminated lupus erythematosus are undoubtedly more common than fnen On the request form full Christian names should be[ errors of identification. and date of birth is a better identification feature than age alone. The date and ti ^ a taking the specimen will show the pathologist what tests are possible and whatne ance must be made for deterioration. Space is always provided for clinical ^ A long essay on the case is not called for. A few well-chosen words will indica ^ duration of illness, the salient clinical features, any tentative diagnosis clinical1; gested and any specific treatment given. Thus "3/12 loss of weight, brile? Ca. stomach? Anaemia. Imferon given" provides the pathologist with a ^ j ground against which he can interpret his findings and possibly suggest or car further tests. Without these few words he is working in the dark. The assi given to the practitioner by a pathological report is often in proportion to the in tion which he gives the laboratory. Time spent on the request form is well spe
^
dyspeps13^?
NOTES ON MORE COMMON
METHODS AND APPLICATIONS OF CLINICAL
Anaemia
PATHOLOgY 10f
.
Where the symptoms point to anaemia, leukaemia or other blood disease a 0d at least 3 ml. of well-shaken unclotted blood should be sent together with a drie ^ film. The drop of blood in the needle may be used for making this film. For r,^ specimens the importance of a well-made film cannot be practitioner should secure a supply of microscopic slides and practise until he can en a really good film. This must be quite dry before it is wrapped in paper and with the bottle. The name may be written in ink over the thick end of the film. A well-made film alone can often be far more informative than a bottle 0 .
over-emphasized. ^
^
blood. tion If the blood shows an iron-deficiency anaemia of low colour index the o^eS. in its cause arises. A B.S.R. estimation can be very helpful, a definite increase that there is some underlying disease process such as infection or neoplasm to ^ anaemia is secondary. A leucocytosis or leucopenia may point to infection, or aD Jfit white cells to leukaemia. In every case of severe unexplained iron-deficiency aan*e x *three a faeces specimen should be sent for occult blood test before and after a or on a white diet. Blood loss is period by far the commonest cause of this type and treatment must be directed to the bleeding point rather than the blood. jui! up examinations only call for haemoglobin estimation at intervals of 2-4 wee blood counts are unnecessary when a diagnosis has been established. t0 If the anaemia is of macrocytic type with high colour index a complete cannot be made on peripheral blood examination alone. A test meal is req determine whether there is achlorhydria and sternal marrow examination is able .(jo11 sary. For the general practitioner a Diagnex (Squibb) tubeless test meal is whether free hydrochloric acid is present or absent. It involves the oral s of the contents of two small cachets and the collection of three timed urine or Estimation of quinine in the urine indicates whether free acid is present Full instructions are given with each outfit. A complete diagnosis requires in addition sternal puncture and a faecal fat ...
^jclj
^jred
a|s togfr0,v a^.mingaInp'e5
CLINICAL
test,
re
?
PATHOLOGY AND GENERAL PRACTICE
113
.
patient to go into hospital and in presence of typical of pernicious anaemia including achlorhydria pictures and Bi2 rjnal B.S.R. then many practitioners are satisfied to give a trial dose of Vitamin ^ave t^ie blood examined for a reticulocyte count in 5 to 10 days. If this resPo Se ls satisfactory, treatment may be continued with confidence. If the anaemia d?es full investigation in hospital is necessary, but by then the vitamin respond, givennot have modified marrow picture. So it is clearly best to have the full invest-may made before thetreatment is given. On no account should the therapeutic test Aatl?* any ma^e because in true Addison's anaemia (true P.A.) folic acid precnv ates ac^ Out sf' devastating nervous involvement. It is possible but not desirable to carry Preljm"1" Puncture as an out-patient procedure. It alarms the nervous patient and
clijjj
ls
.
an? {fy within three hours of taking. In view of the value of the test a number of a ^ practitioners remote from the laboratory have found it worth while to acquire rack and a number of Westergren tubes. These are obtainable commercially acute
diseases
may be raised.
fibrinogen
It is sometimes stated that
'
c?.^ple
laboratory supply The procedure
houses. is simple.
cjtr^te
bottle of 3-8 per cent, sodium solution. Fill the pipette to the 150 mm. mark (i.e. one quarter full) with^ ^ solution and place it in a small test-tube. To this add one pipette full to the with blood from the specimen before it is sent to the laboratory for the count. ^ and citrate are mixed and the pipette is then filled with diluted blood to the rt13 gJ1js kit j placed vertically in the stand. A simple timing device such as used in the set to ring after one hour. If the doctor himself cannot be present to read it, the ^ level after one hour may be exactly marked by sticking a piece of adhesive papef e^t inte even a task is the of or which well within tube, wife, secretary competence daily help, after instruction. The upper limit of normal is 15 mm. in 1 hour. The other extreme is repreS by myelomatosis where rates of over 100 mm. in one half hoar are common. Have at hand
a
u^jo0(i .
^ed
Suspected Infection, Acute and Chronic In any patient with a fever of unknown origin the appropriate investigations on the differential diagnosis; this of course varies from case to case. Pfltn ^ material, sent for bacteriological examination, should include urine in eVer^jable' with swabs, faeces, vomitus, sputum, pus or serous effusions where they were The initial routine investigation may also include (1) unclotted blood for tests ful^ an count, B.S.R. and biochemical tests, (2) clotted blood for serological tests c such as the flocculation reactions which are used in hepatitis, and (3) blood ^ M The B.S.R. and the leucocyte picture may then suggest a group of infection^ be ?$. further as Paul Bunnell tests such the may investigated by serological glandular fever, cold agglutination or M.G. streptococcus test in primary yjf115 virus pneumonitis, or the Brucella agglutination tests. In the case of suspecte ^ ?^ and rickettsial infections a specimen of serum secured early in the disease Is vjfiis value as it can be compared with a second specimen taken in convalescence. serology such paired specimens are necessary in view of the great differences ^eI-elS individuals in the normal antibody titres. When blood culture is called for no substitute for an autoclaved syringe and needle in a sealed container whicl Q pi ^1. obtained from the laboratory before use. In carrying out the routine describe ?
of blood
cU^??'
desirable of which 10 ml. are added to a bottle of broth for and 5 ml. collected in a plain bottle for serum. rna{i?5lS in the needle is then used for making a blood film. If malaria is a possible a thick smear is also made on the central one-third of a further side and weM Urine from female patients must be taken by catheter if the bacteriological tion is important. In a male a mid-stream specimen passed directly into a s bottle is satisfactory. are
mixed with
anticoagulant
!LrjliZe
CLINICAL
PATHOLOGY AND GENERAL PRACTICE
115
^seases e
Ending
of albuminuria should always call for a complete examination of the and cultural examination of the deposit. If evidence of renal ^ th k Presenl a blood urea estimation should be made. Further help may be given "lood urea is combined with the urea clearance test. For this test two samples ,ne are required each representing 60 minutes' renal output. The urine and blood are sent to the laboratory and the clearance as a percentage of normal can be ed. It is essential that the bladder is empty before collection of the timed specj ns commenced and if the time intervals differ from 60 minutes the exact tiitig minutes should be stated no each bottle. The whole of the timed specimen Sent because the calculation requires the renal output in ml. per minute, which may be helpful in chronic disease are serum cholesterol estimation and reserve f?r which a clotted blood sample collected under a one-half-inch
Urin e d;s
microscopic
of*
calcfi63 ?
$h0lll'n Other lutests
%er
f
?
liquid paraffin
is
required.
by g gr^static cases, besides a urine examination valuable information may be given haemoglobin, blood urea and acid and alkaline phosphatase determinations.
whether or not there is a carcinoma with or without bone secondaries. Five Sljl8?est of E.D.T.A. (or potassium oxalate) blood are sufficient for all these tests, Byu ?
.
these
be s
o
Jn
tests
arriving
carried
out
before the
diagnosis
at a
and
patient sees the surgeon, valuable time determining suitability for surgery.
of Gly ^Sation Ending reducing Afuij6
substance in the urine calls for
Henta 5leSP.ecimen passed
the
may
cosuria
of
a
a
blood-sugar
estimation,
Ucose tolerance test is not always necessary in the first place. A single "sighting be all that is required and blood taken two hours after a good carbohydrate meal, e.g., breakfast will usually show whether the glycosuria is important.
shot"
at
same
time, examined for
sugar and acetone,
supple-
tory f ^formation given by blood sugar. One has seen a patient sent to the laboralbe fa r. ?Wose tolerance test showing clinical evidence of severe diabetes, in whom blood sugar gluCOselng ^V0llld.be ill-advised.
600 mg. per cent. In such a patient a dose of 50 g. of If the result of the single test is in any way equivocal the ?Ur glucose tolerance test should be carried out at the laboratory. Glv in pregnancy is usually physiological when it is due to milk sugar but ,SUria any 0ubt exists a single blood-sugar test as described is far more useful than a lrnen for osazone or fermentation tests which are tedious to perform and i conclusive where only a trace of reducing substance is present. was over
full
^ete J?Undice
is the presenting feature a simple series of tests may be carried out whether it is due to biliary obstruction or to infective hepatitis. Five ml. clott ^ed are olood are required and a urine specimen should also be sent. The estimations serum bilirubin and serum alkaline phosphatase with serum colloidal gold, ^he Ur^dity and thymol flocculation tests. tlve bile in the urine will show that the icterus is of hepatic or obstrucan
