John C. DaCosta.

Clinical hematology : a practical guide to the examination of the blood with reference to diagnosis online

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WM^^^^



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THE LIBRARY

OF

THE UNIVERSITY

OF CALIFORNIA



PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID

PUBLIC
HEALTH
LIBRARY









^




CC^t^fCtyo




X^, i^^ . ^ ^' /9o ^



CLINICAL HEMATOLOGY
DaCOSTA



CLINICAL

HEMATOLOGY

A PRACTICAL GUIDE

TO THE

EXAMINATION OF THE BLOOD WITH
REFERENCE TO DIAGNOSIS.



By



JOHN C. ^aCOSTA, Jr., M.D.

ASSISTANT DEMONSTRATOR OF CLINICAL MEDICINE, JEFFERSON MEDICAL COLLBGE
HEMATOLOGIST TO THE GERMAN HOSPITAL, ETC.



Containing Eight Full-Page Colored Plates, Three Charts,
AND Forty-Eight other Illustrations.




PHILADELPHIA :
P. BLAKISTON'S SON & CO.

IOI2 WALNUT street
1902



Copyright, 1901,
P. Blakiston's Son & Co.



i^i'l



? Lib He

Lih



TO

MY FATHER,
JOHN C DaCOSTA, M.D.,

THESE PAGES ARE

AFFECTIONATELY DEDICATED.



ivi37eQ5£



oo



PREFACE.

This book, designed as a practical guide to the examination of
the blood by methods adapted to routine clinical work, repre-
sents an endeavor to recount the salient facts of hematology as
they are understood at the present time, to correlate certain of
these facts with familiar pictures of disease, and to apply them to
medical and surgical diagnosis. The purpose has been to inter-
pret the blood report according to its true value as a clinical sign,
neither exploiting it as a panacea for every diagnostic ill, nor
belittling it because of its failure consistently to give the sought-
for clue in every instance.

A minimum amount of theoretical discussion has been intro-
duced in the sections dealing with the physiology and pathology
of the whole blood and of the cellular elements — only sufficient,
in the author's judgment, to add clearness to a number of the
mooted points of this science, which in its present transitional
stage must still be regarded as one from which more or less hy-
pothesis and conjecture are inseparable. Intimate familiarity with
technique being an essential qualification for the comprehensive
study of the blood, a somewhat lengthy consideration of this sub-
ject is given. The methods of examination likely to prove useful
in every -day practice have been described in detail, perhaps some-
times at the risk of prolixity, in the hope of thus simplifying for
the novice the minutiae of blood counting, staining, and other
means of investigation. In the discussion of the primaiy anemias
and of the anemias peculiar to infancy, prominent clinical features
other than those referable to the blood have been briefly men-
tioned, in order to add clearness to the differential diagnosis. For
convenience in reference, the various diseases included in the sec-
tion on general hematology are arranged alphabetically, rather
than grouped according to a traditional classification.

The greater part of the original data referred to in the text is
taken from the records of the Pathological Institute of the Ger-
man Hospital, where a systematic account of all blood examina-
tions has been kept for the past six years. The remaining data
represent the writer's personal examinations in hospital and pri-
vate practice and in the army medical service, these sources of
statistics together including about four thousand blood reports in

various pathological conditions.

vii



VIU PREFACE.

Hematological literature has been freely consulted in the prep-
aration of this volume, special acknowledgment being due to
Hayem, Ehrlich and Lazarus, von Limbeck, Rieder, Lowit,
Tiirk, Grawitz, Cabot, Stengel, Thayer, Ewing, Taylor, and Coles
for the profitable information gleaned from their writings. Due
credit in the text has been given to these as well as to the other
authors of whose labors use has been made.

The colored plates and other histological illustrations, the
originals of which were made by Mr. E. F. Faber from fresh and
stained specimens, bear evidence of the artist's technical skill and
faithful attention to structural detail. ^Ir. S. Trenner has kindlv
furnished the engravings of several of the special instruments.

The author takes pleasure in acknowledging the assistance of
his wife and critic in revising the proof of these pages ; in credit-
ing Dr. G. P. Miiller for collecting and verifying much statistical
matter relating to hospital cases ; and in thanking Dr. J. Chal-
mers Da Costa and Dr. T. G. Ashton for helpful suggestions.

313 South Thirteenth Street, Philadelphia,
November, 1901.



INTRODUCTION.



The rapid growth and development of hematology during re-
cent years and the practical application of many of its teachings
to the diagnosis of various diseases have made this science one
which no progressive medical man can afford to disregard. Ex-
amination of the blood gives definite clinical information which
may be profitable both to the practitioner of internal medicine
and to the surgeon, and the procedure is capable of throwing
light upon the diagnosis in such a wide range of pathological
conditions that it is difficult to single out any disease in which it
may not be of some utility, either as positive or as negative evi-
dence.

In the light of our present knowledge of the subject, clinical
information of two different kinds may be derived from hematol-
ogy, namely, findings which are pathognomonic of certain dis-
eases ; and auxiliary data which, if considered in connection with
other clinical manifestations, may prove either essential or helpful
in establishing the precise nature of a disease.

Pathognomonic blood findings are unfortunately confined to a
limited number of diseases : leukemia, the malarial fevers, relaps-
ing fever, and filariasis. In pernicious anemia a typical picture
is also found, if two conditions capable of exciting identical blood
changes are excepted, the profound secondary anemias due to
certain intestinal parasites and to nitrobenzol poisoning.

The blood examination affords data which, although not pa-
thognomonic, are nevertheless essential for the diagnosis of chlo-
rosis, Hodgkin's disease, splenic anemia, and secondary ane-
mias dependent upon various causes. For example, in chlorosis
a definite group of blood changes must exist in order to justify
an unconditional diagnosis, although the occurrence of these
changes, unassociated with other equally definite clinical signs,
is insufficient evidence of this disease. In Hodgkin's disease, a
condition indistinguishable from leukemia by an ordinary phys-
ical examination, the absence of a leukemic state of the blood at
once excludes the latter disease. In the secondary anemias, it is
obvious that the blood count alone can give the exact clue to the
condition, by determining the degree and character of the blood
impoverishment, and by tracing from time to time its progress.



IX



X INTRODUCTION.

In this connection it is important to remember that pallor may
go hand in hand with a normal hemoglobin percentage and eryth-
rocyte value, and that on the other hand a high color by no
means invariably signifies that the individual is not anemic. In
addition to the diseases just named, hematology' gives informa-
tion which is often of great assistance in, although not essential
for, the diagnosis of such conditions as enteric fever, sepsis,
pneumonia, appendicitis, diabetes, syphilis, malignant disease,
trichiniasis, and suppurative processes. Clinical experience has
repeatedly illustrated the value of the serum reaction in typhoid
and in Malta fevers, of Williamson's test in diabetes mellitus, of
eosinophilia in trichiniasis, and of leucocytosis in sepsis, malignant
neoplasms, suppurative lesions, and many of the acute infections.

Negative results from a blood examination also possess diag-
nostic value within certain limits, but too great reliance upon evi-
dence of this sort more often proves delusiv^e than helpful. In a
patient whose waxy, yellowish facies suggests with equal force
pernicious anemia, chronic nephritis, and, perhaps, liver cirrhosis,
the absence of characteristic blood changes is sufficient to exclude
the first-named condition. But failure to detect the malarial para-
site does not necessarily exclude malarial fever ; a negative serum
test does not absolutely rule out enteric fever; and an absence of
leucocytosis cannot be regarded as an infallible sign that a sup-
purative focus does not exist, nor does it always indicate the
benignity of a neoplasm. Negative evidence, then, is usually to
be considered merely suggestive, the real pertinence of the hint
thus obtained depending upon its correlation with other physical
signs and symptoms.

The significance of positive findings in bacteriological investiga-
tions of the blood is patent, and the conclusive value of this
means of research in identifying obscure cases of general sepsis,
malignant endocarditis, enteric fever, and plague, has been demon-
strated in many instances. Thje conflicting and indifferent results
which some investigators hav^e obtained by this procedure were
doubtless due largely to faulty technique, but these results promise
to become more dependable and certain with the adoption or
more exact technical methods.

At the present time the most useful information furnished by
hematology' has been derived from study of the cellular elements
of the blood, but closer familiarity with the chemistry of this
tissue, still an undeveloped science, will undoubtedly in the near
future afford not only more tangible clues to the etiology and
pathology of the blood diseases, but also will bring to light addi-
tional facts which may be applied to the diagnosis of these and



INTRODUCTION. XI

other maladies. The study of the coagulation time of the blood
already promises to be of practical utility in the diagnosis and
prognosis of cases of purpura, hemophilia, and jaundice, which
are characterized by slow clotting and by a tendency toward
hemorrhage.

The technique of blood examinations, such as described in
the following pages, is neither elaborate nor difficult to master.
Necessarily, it must be rigidly exact, but no more so than any
other branch of physical diagnosis, if the worker is content only
with the best results. To acquire a good working knowledge of
hematology takes but a fraction of the time and application that
one must spend in familiarizing one's self with the most com-
mon heart murmurs or chest signs, and the time thus spent
equips the physician with an additional diagnostic agent of the
greatest value. If the newly-graduated physician would provide
himself with a microscope and a set of blood instruments, and
systematically study the blood in the various general diseases
which he encounters in practice, many a slip-shod diagnosis
might be avoided, and a great stride forward made in popularizing
this practical branch of clinical diagnosis.



TABLE OF CONTENTS.



INTRODUCTION



IX



SECTION I.
EXAMINATION OF THE BLOOD BY CLINICAL METHODS.

Page.



General Schema



I.



Hemoconia



Hemoglobin



Examination of the Fresh Blood
Obtaining the Specimen
Preparing the Shde
Microscopical Examination .
Changes Affecting the Erythrocytes
Changes Affecting the Leucocytes .
Increase of Fibrin, Blood Plaques, and
Blood Parasites . • • •

Foreign Bodies . • • •

II. Estimation of the Percentage of

Von Fleischl's Hemometer
Ohver's Hemoglobinometer
Gowers' Hemoglobinometer
Dare's Hemoglobinometer
Tallquist's Method

III. Counting the Erythrocytes and the Leucocytes
Methods . • • •
Diluting Fluids

The Thoma-Zeiss Hemocytometer
Counting the Erythrocytes •
Counting the Leucocytes
Cleaning the Pipette
Durham's Hemocytometer •
Gowers' Hemocytometer
Ohver's Hemocytometer

IV. Microscopical Examination of the Stained Specimen ,
Objects of Staining
The Anihne Dyes .
Preparing the Films
Fixation Methods .
Methods of Staining
Ehrhch's Triacid Stain
Jenner's Stain
Prince's Stain

xiii



19

19

19
21

22

22

23
24
24
24

25
25
32
34
36
39

40
40
40

42

45
49
52
52
54
56

58

58

59

59
61

63
64

65
66



XIV



TABLE OF CONTENTS.



Staining with Eosin and Methylene-blue
Staining with Eosin and Hematoxyhn .
Staining with Thionin ....
Staining with Polychrome Methylene-blue
Differential Counting ....

V. Counting the Blood Plaques •

Determann's Method ....

VI. Estimation of the Relative Volumes of Corpuscles an

Plasma ......

Daland's Hematocrit ....

Limitations of the Hematocrit

VII. Estimation of the Specific Gravity
Hammerschlag's Method . • .

VIII. Estimation of the Alkalinity
Engel's Alkalimeter

IX. Determination of the Rapidity of Coagulation
Glass Slide Method
Wright's Coagulometer

X. Spectroscopical Examination .

The Sorby-Beck Microspectroscope

XI. Bacteriological Examination
Value of Positive Findings
Methods .....
Blood Cultures . . • •
Staining Methods

XII. Determination of the Serum Reaction
Widal'sTest ......

The Specific Test for Human Blood



D



Page.
67

68
69
69
70

71

72



72

73
74

75
75

n
77

79
80
80

81
81

83
83
83
83

85

86
86
88



SECTION II.
THE BLOOD AS A WHOLE.



I. General Composition .

Plasma, Serum, and Cells
Salts .
Extractives
Gases .

II. Color .

Normal Variations
Density and Opacity
Pathological Variations

III. Odor and Viscosity

IV. Reaction
Reaction in Health



93
93
93
94
94

94
94
94
94

95

95
95



TABLE OF CONTENTS.



XV



Table of Normal Blood Alkalinity .








96


Physiological Variations . . . .








96


Pathological Variations . . . . .








97


V. Specific Gravity ......








98


Normal Range .....








98


Pathological Variations ....








99


Relation of Specific Gravity to Hemoglobin








99


Table of Hemoglobin Equivalents .








100


VI. Fibrin and Coagulation . . . .








100


Relation of Fibrin to Coagulation








100


Appearance of Fibrin in Fresh Blood








lOI


Hyperinosis and Hypinosis .








102


Pathological Variations in Amount of Fibrin .








102


VII. Oligemia .......








103


Definition ......








103


Occurrence ......








103


VIII. Plethora ......








104


Definition ......








104


Permanent and Transient Polyemia








104


Serous Plethora .....








104


Cellular Plethora .....








105


IX. Hydremia ......








105


Definition ......








105


Causes .......








105


Occurrence ......








105


X. Anhydremia








106


Definition ......








106


Causes .......








106


Occurrence ......








106


XI. LiPEMIA ......








106


Amount of Fat in Normal Blood •








106


Definition . .








107


Physiological and Pathological Lipemia .








107


Tests for Fat .....








107


XII. Melanemia








107


Definition ......








107


Occurrence ......








108


XIII. Glycemia








108


Amount of Sugar in Normal Blood








108


Hyperglycemia .....








108


Test for Sugar .....








108


XIV. Uricacidemia








109


Definition ......








109


Occurrence ......








109


Test for Uric Acid .....








109



XVI



TABLE OF CONTENTS.



XV. Cholemia . . . . .
Definition . . . . .
Occurrence . . . . .
Test for Bile . . . .

XVI. Acetonemia and Lipacidemia
Definition . . . . •
Occurrence . . . .
Tests for Acetone and Fatty Acids

XVII. Bacteriemia .
Occurrence
Latent Infection
Blood Cultures
Bacteria Found in the Blood



XVIII. Anemia .
Definition
Pseudo-anemia
Classification
Patho2"enesis



Page,


I lO


IIO


IIO


IIO


IIO


IIO


IIO


IIO


III


III


III


112


112


113


113


113


114


115



SECTION III.

HEMOGLOBIN. ERYTHROCYTES, BLOOD PLAQUES,
AND HEMOCONIA.



II.



III.



Hemoglobin














119


General Properties














119


Origin














120


Variations in Amount














121


Absolute Amount














122


Color Index














122


Hemoglobinemia














123


Methemoglobinemia














124


Carbon Monoxide Hemoglobin












125


Erythrocytes












126


Appearance in Fresh Blood .












126


Histological Structure .












127


Origin and Life History-












128


Size

Normal Number .












129
129


Volume Index












130


. Influence of Physiological Factors 0:


S' THE ERYTH- .


rocytes .....


130


Age and Sex .....
Pregnancy, Menstruation, and Lactation






130
131


Constitution and Nutrition






132


Fatigue

Digestion and Food

High Altitudes















132
132
133



TABLE OF CONTENTS.



XVI 1



IV. Pathological Changes in the
Ameboid Motility
Alterations in Isotonicity
Hyperviscosity
Deformities of Shape and Size

Megalocytes .

Microcytes

Poikilocytes
Endoglobular Degeneration
Total Necrosis
Atypical Staining Reactioi>
Nucleation .

Normoblasts

Megaloblasts

Microblasts .

Atypical Erythroblasts
Granular Degeneration
Oligocythemia
Polycythemia

V. Blood Plaques

Appearance in Fresh Blood

Histological Structure .

Origin

Normal Number .

Pathological Variations

VI. Hemoconia
Appearance in Fresh Blood
Histological Characteristics
Occurrence .



Erythrocytes



Page.

135
136

136
136
137
137
138

139
140

141

141

143

145
146

147
148
149



SECTION IV.



THE LEUCOCYTES.



General Characteristics
Appearance in Fresh Blood
Ameboid Movement
Cell Granules
Normal Number .



H. Classification

Number and Percentage
Small Lymphocytes
Large Lymphocytes
Transitional Forms
Polynuclear Neutrophiles
Eosinophiles
Basophile Cells
Myelocytes .
Mast Cells .
1*



of Different Varieties



»55

155

156

157
159

159

159
160

161
162
163
165
166
167
168



XVlll



TABLE OF CONTENTS.



Mononuclear Neutrophiles

Neutrophilic Pseudolymphocytes

Reizungsformen .

Differential Table of the Leucocytes

Origin and Development

Iodine Reaction .

Perinuclear Basophilia .



toses



III. Leucocytosis

Definition ....
Classification of the Leucocyte
Physiological Leucocytosis

Character

Causal Factors

Leucocytosis of the New-born

Digestion Leucocytosis



Leucocytosis of Pregnancy and Parturition
Leucocytosis Due to Thermal and Mechanical
Terminal Leucocytosis ....
Pathological Leucocytosis
Occurrence
Degree of Increase
Differential Changes
Causal Factors

Functions .....
Hypoleucocytosis and Hyperleucocytosis
Inflammatory and Infectious Leucocytosis
Leucocytosis of Malignant Disease
Post-hemorrhagic Leucocytosis
Toxic Leucocytosis
Experimental Leucocytosis



IV. Lymphocytosis .
Definition

Differential Changes
Causal Factors
Physiological Lymphocytosis
Pathological Lymphocytosis .
Experimental Lymphocytosis
Clinical Significance



EOSINOPHILIA ....

Definition .....
Causal Factors ....
Physiological Eosinophilia
Pathological Eosinophilia
Experimental Eosinophilia
Diminution in the Number of Eosinophiles
Clinical Significance ....



Influences



Pagb.
171
171

171
172

173
176

176
176
177
177
177
178
178
179
180
iBi
181
182
182
183
183
184
184
185

187
190
191
192

193

196
196
196
197
197
197
198
198

198
198
199
199
200
201
201
201



VI. Basophilia .



202



TABLE OF CONTENTS.



XIX



VII. Myelemia .
Definition
Occurrence .
Causal Factors

VIII. Leucopenia
Definition

Differential Changes
Physiological Leucopenia
Pathological Leucopenia
Experimental Leucopenia



Page.
202
202
202
203

203
203
204
204
205
207



SECTION V.

DISEASES OF THE BLOOD.

I. Chlorosis ....

Appearance of the Fresh Blood
Coagulation ....
Specific Gravity
Alkalinity ....
Hemoglobin and Erythrocytes
Color Index ....
Deformed and Nucleated Cells
Leucocytes ....
Differential Changes
Blood Plaques

Diagnosis ....
Clinical Features .

II. Pernicious Anemia

Appearance of the Fresh Blood

Coagulation ....

Specific Gravity .

Alkalinity ....

Hemoglobin and Erythrocytes

Color Index ....

The Blood During Remissions

Megalocytosis

Poikilocytosis

Prevalence of Megaloblasts .

Polychromatophila

Granular Basophilia

Leucocytes ....

Differential Changes

Blood Plaques

Diagnosis ....

Clinical Features .

Pernicious Anemia and Severe Secondary Anemia

Pernicious Anemia and Chlorosis .

Pernicious Anemia and Bothriocephalus Anemia

Pernicious Anemia and Nitrobenzol Poisoning



209
209
209
209
219
210
210
210
213
214
215
216
216

218

2X8

219
219
220
220
220

221
221
223
224
225
226
227
227
228
228
229
230
230
231
231



XX



TABLE OF CONTENTS.



III. Splenic Anemia.
Appearance of the Fresh Blood
Hemoglobin and Er>'throcytes
Color Index .

Deformed and Nucleated Cell
Leucocytes .
Blood Plaques
Diagnosis
Clinical Features .
Splenic Anemia and Spleno-medullar)' Leukemia
Splenic Anemia and Pernicious Anemia
Splenic Anemia and Hodgkin's Disease
Splenic Anemia and Splenic Tumors

IV. Secondary Anemia
Appearance of the Fresh Blood
Coagulation .
Specific Gravity
Alkalinity

Hemoglobin and Erythrocytes
Color Index .

Deformed and Nucleated Cell
Leucocytes .
Differential Changes
Blood Plaques
Diagnosis

V. POST-HEMORRHAGIC AnEMIA

Etiology

Immediate Effects of Hemorrhage
Secondary Effects of Hemorrhage .
Degree of Blood Loss Compatible with Life
Regeneration of the Blood

Differential Table .....

VI. Leukemia ......

Varieties ......

Parasitology ......

Spleno-medullar)- Leukemia .

Appearance of the Fresh Blood
Coagulation .....

Alkalinity

Specific Gravity ....

Hemoglobin and Erj-throcytes
Color Index .....

Relation of Erythrocyte and Leucocyte Counts

Nucleated Cells

Leucocytes ......

Influence of Arsenic on the Leucocyte Count
The Blood During Remissions
Differential Changes ....

Blood Plaques .....



Page.
231
231
231
231
232
233
233
233
234
235
235
235
235

236
236
236
236
237
237
237
238
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239

239
240

240

240

241

243

244
244
244
246
246
247
247
247
247
248
248
248
250
250
251
252
256



TABLE OF CONTENTS.



XXI



Lymphatic Leukemia

Appearance of the Fresh Blood

Hemoglobin and Erythrocytes

Color Index . . . •

Deformed and Nucleated Cells

Leucocytes ....

Differential Changes

Blood Plaques
Acute Leukemia ....
Influence of Intercurrent Infections
Diagnosis ....••
Spleno-meduUary and Lymphatic Leukemia
Leukemia and Pathological Leucocytosis
Leukemia and Lymphocytosis
Leukemia and Hodgkin's Disease •
Leukemia and Tumors of the Spleen, Kidney, and Pancreas
Leukemia and Lymphatic Hyperplasia .

VII. Hodgkin's Disease ....
Appearance of the Fresh Blood
Alkalinity, Specific Gravity, and Coagulation
Hemoglobin and Erythrocytes
Color Index ....••
Nucleated and Deformed Cells
Leucocytes ...•••
Differential Changes ....
Diagnosis ....••
Clinical Features . . . • •
Hodgkin's Disease and Tuberculous Adenitis
Hodgkin's Disease and Syphilitic Adenitis
Hodgkin's Disease and Local Lymphoma
Hodgkin's Disease and Lymphatic Sarcoma .
Hodgkin's Disease and Lymphatic Carcinoma

VIII. The Effect on the Blood of Splenectomy
Hemoglobin and Erythrocytes ....
Leucocytes ....••••

Differential Changes

Factors of the Blood Changes Following Splenectomy

Differential Table .



Page.
256
256
257
257
257
258
259
260
260
261
263
264
265
265
266
266
266

267
267
267
267
267
267
268
268
269
270
271
271
271
271
272

272
272
272
274
274

275



SECTION VI.
THE ANEMIAS OF INFANCY AND CHILDHOOD

I. Characteristics of the Blood in Children

Fetal Blood .
The Blood at Birth

II. Anemia in Children

Frequency .
General Characteristics



279
279
280

282
282
283



XXll



TABLE OF CONTENTS.











Page.


Classification . 283


Primary Anemia . . • •
Pernicious Anemia








284
284


Leukemia ....








284


Secondary Aremia

Mild Anemia . . ■ •








287
287


Severe Anemia








287


Anemias with Leucocytosis








287


Etiology of Secondary Anemia
Anemia Due to Syphilis .








288
288


Anemia Due to Rachitis .








288


Anemia Due to Tuberculosis •








289


Anemia Due to Gastro-intestinal Diseases






289


Post-typhoid Anemia ....
Anemia Infantum Pseudoleukemica






289
290


Bacteriemia in Children









292



SECTION VII.



GENERAL HEMATOLOGY.

I. Abscess



Online LibraryJohn C. DaCostaClinical hematology : a practical guide to the examination of the blood with reference to diagnosis → online text (page 1 of 48)