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DIAGNOSTIC METHODS



WEBSTER



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DIAGNOSTIC METHODS

CHEMICAL, BACTERIOLOGICAL
AND MICROSCOPICAL



A Text-book for Students and Practitioners



BY

RALPH W. WEBSTER, M. D., Ph. D.

ASSISTANT PROFESSOR OF PHARMACOLOGICAL THERAPEUTICS AND INSTRUCTOR IN MEDICINE IN

RUSH MEDICAL COLLEGE, UNIVERSITY OF CHICAGO; DIRECTOR OF CHICAGO

LABORATORY, CLINICAL AND ANALYTICAL



FIFTH EDITION, REVISED AND ENLARGED

WITH 37 COLORED PLATES

AND 171 OTHER ILLUSTRATIONS



"'■o



I \



PHILADELPHIA
BLAKISTON'S SON & CO,

1012 WALNUT STREET
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No.5:^i°i



FiEST Edition, Copyright, 1909, by P. Blakiston's Son & Co.
Second Edition, Copyright, 191 2, by P. Blakiston's Son & Co.
Thibd Edition, Copyright, 1913, by P. Blakiston's Son & Co.
Fourth Edition, Copyright, 1914, by P. Blakiston's Son & Co.
Fifth Edition, Copyright, 1916, by P. Blakiston's Son & Co.



W 3S




THE MAPLE PRESS YORK PA ^

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TO THE MEMORY

OF

MY PATHER
DR. JOHN RANDOLPH WEBSTER

THIS VOLUME IS

LOVINGLY DEDICATED



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PREFACE TO THE FIFTH EDITION



During the last year, investigation along all scientific lines has been greatly
curtailed for self-evident reasons. However, sufficient new material, both as
regards methods and general points of attack, is at hand to warrant quite
extensive changes in the subject matter of this work.

Among the additions will be found Petroff's method of obtaining pure cul-
tures of tubercle bacilli; a discussion of the Endameba gingivalis; description
and methods of study of Bacillus rhinitis; Wolff-Junghans' test for gastric
carcinoma; Wagner's "dry test" for occult blood; Phenoltetrachlorphthalein
test of hepatic activity; Urease method for urea; Folin's new method for crea-
tinin in urine; Benedict and Murlin's method for amino-acids in urine; Folin
and Denis' micro-chemical methods for non-protein nitrogen, urea and uric
acid in the blood; Schick diphtheria toxin reaction; Bronfenbrenner's modifi-
cation of Abderhalden's test; and tests of blood before transfusion. The
subject matter throughout the text has been brought up to date by the inclu-
sion of a large number of references to the original literature.

The author wishes to express his extreme gratification at the reception of
his former editions and, also, his deepest thanks for any and all criticisms
which he has obtained from his reviewers and friends. He desires, especially,
to acknowledge his indebtedness to Dr. F. B. Moorehead for his kindly criti-
cism of the section on Endameba gingivalis.

Ralph W. Webster.
25 E. Washington St., Chicago.



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PREFACE TO THE FOURTH EDITION



Although less than a year has elapsed since the appearance of the third edi-
tion of this work, the author has felt justified in adding considerable new
material in this revision. This has come about largely through the sugges-
tions of teachers and general practitioners regarding the inclusion of certain
subjects not hitherto discussed.

Thus, the new matter embraces, among other subjects, a discussion of the
Negri bodies recently successfully cultivated by Noguchi; Weisz's test for
urochromogen; Dorrance's method for coagulation of the blood; Kowarsky's
method for glucose in the blood; Levaditi and Manouelian's as well as Nogu-
chi's methods for staining spirochsete in tissue; Lange's colloidal-gold test for
congenital syphilis; a discussion of the organism of anterior poliomyelitis
recently cultivated by Flexner and Noguchi. The Wassermann test has
been brought up to date by inclusion of considerable new matter; while
the complement-fixation test in gonorrhea has been elaborated. The Her-
man-Perutz reaction for syphilis is fully described. The application of
Abderhalden's dialyzation method to the diagnosis of cancer and dementia
praecox has been freely discussed. Further, an entirely new chapter on
Clinical Bacteriology has been added, in which are . discussed the differen-
tiation of the more important pathogenic organisms and, also, the methods
of preparation of vaccines. The subject matter throughout the text has
been brought up to date by the inclusion of a large number of references to
the original literature.

The author wishes to express his great satisfaction at the reception of the
third edition of his work and, also, his full appreciation of the kind sugges-
tions offered him regarding the general matter of the book. He wishes,
especially, to thank his colleagues Drs. T. L. Dagg and C. C. Croy for their
many valuable suggestions and criticism.

Ralph W. Webster.
2$ E. Washington St., Chicago.



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PREFACE TO THE FIRST EDITION



In the present work the writer has attempted to bring together, for the
use of the student and practitioner, the generally accepted facts regarding the
various phases of clinical medicine, which may be rather more closely studied
by the application of laboratory methods than without their use. It is to be
especially emphasized that laboratory work must go hand in hand with the
more direct clinical examination of the patient, as the former can be inter-
preted only in the light of the latter. While it is true that, in some cases,
the laboratory findings may be of even more value than those of physical ex-
amination, yet it is to be understood that the function of the Clinical Labora-
tory is, more largely, perhaps, an accessory one, the application of methods of
physical diagnosis usually pointing out the way toward a successful solution
of the clinical problem by special laboratory methods, which yield numerous
confirmatory or differential points not at all clearly defined by the methods of
direct clinical examination.

The aim of the author has been to present the direct bearing of the various
methods outlined upon the clinical history of the case and to point out the
special interpretation of the findings in any given examination. Particular
attention has been directed to the selection of methods, both for the simpler
clinical and more complex scientific requirements. As no method, no matter
how exact it may be or how sound its basic principle, will yield reliable re-
sults in the hands of the inexperienced, the writer has paid much attention to
the details of such methods and has endeavored to direct the thought of the
worker to the possible obstacles to be overcome before he is able properly to
perform these examinations and interpret his results.

The writer makes no claim for originality except, possibly, in the matter of
arrangement of subject-matter and selection of methods and ideas, which
have been established by others after years of earnest research. His endeavor
has been to be as catholic as possible in his reading and as selective as his
judgment permitted, to the end that the student or practitioner be saved the
burden of sifting the wheat from the chaff.

• Numerous text-books, monographs, and special articles have been freely
used in the preparation of the text, the writer attempting in each case to give
due credit for such reference. It Is possible that some direct use of material
has been made which has not received deserved recognition. If so, the writer
here acknowledges his indebtedness to them as well as to those whom he has
directly quoted.

It has seemed desirable to omit extensive reference to the literature, as a
bibliography to be of working value must be much more extensive and com-

xi
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Xll PREFACE

plete than is possible within the scope of this book. The writer has, however,
inserted at the end of each chapter a list of the more important larger works
which he has found useful in correlating the general subjects included in the
several sections.

In conclusion, the writer wishes to express his deep obligation to his col-
leagues for their many valuable suggestions as to the subject-matter of the
text: to Prof. W. S. Haines for assistance in revising the section on Urine; to
Dr. J. M. Washburn for many additions and revisions of the section on Blood;
to Dr. O. J. West for many practical points throughout the whole work; to
Dr. W. A. Pusey for photographs of Blastomycetes under various conditions;
to Dr. Brown Pusey for slides showing various organisms in the conjunctival
exudates; and to Dr. N". Gildersleeve, of the University of Pennsylvania, for
illustrations of megalosporon and microsporon. Further, the writer wishes
to express his thanks to Miss Hill for the excellent work done by her in pre-
paring the original drawings which appear throughout the work.

Ralph W. Websteb.



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TABLE OF CONTENTS



CHAPTER I
The Sputum

Page

I. General Considerations i

II. Physical and Chemical Characteristics 2

Amount ,, 2

Consistency 2

Reaction. 3

Color 3

Odor 4

Character 4

Chemistry 5

III. Macroscopic Examination 6

Cheesy masses 6

Dittrich's plugs 6

Curschmann's spirals 7

Fibrinous casts 8

Concretions 8

Bronchioliths 8

Pneumoliths 8

' Echinococcus membranes . . ... 9

Foreign bodies . 9

IV. Microscopic Examination 9

Pus-cells 10

Red blood-cells .... . 11

Epithelial cells . 11

Elastic tissue . . . . 12

Crystals 13

Bacteria. 14

Saprophytes 14

Pathogenic types 17

Tubercle bacillus 17

Lepra bacillus 24

Smegma bacillus 24

Timothy bacillus . 24

Pneumococcus .25

Friedlander's bacillus .... 25

Influenza bacillus . 26

BacOlus pertussis .... ... . . 26

Bacillus typhosus . . ... .... 26

Staphylococcus and streptococcus pyogenes . . . .26

Bacillus pestis . . .... 27

Bacillus anthracis ... 27

Bacillus mallei . . . .... .... 27

Actinomyces hominis .... 27

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Page

Animal parasites . ^°

Amebae ... 28

Flagellates . . ... 28

Cestodes. . . . ... • 29

Tfematodes . . ... 29

V. The Sputa in Disease . . . 30

Pulmonary tuberculosis ... • 3°

Croupous pneumonia 3i

Broncho-pneumonia . ... 31

Acute bronchitis . ... 31

Chronic bronchitis ■ ■ • 32

Simple type 32

Putrid type ■ 32

Fibrinous type 32

Bronchial asthma . . 33

Influenza . . 33

Gangrene of the lung 33

Abscess of the lung . 33

Perforating empyema 34

Pneumonoconioses . . 34

CHAPTER II

Oral, Nasal, Aural and Conjunctival Secretions

I. Oral Secretion . . 35

General considerations. . . 35

Microscopic examination . . . ... -36

Pathologic changes ... ... 37

Pharyngomycosis leptothrica . . 38

Diphtheria . . . . . . 38

Vincent's angina . . . 40

Streptococcic sore throat. . 40
Gonorrheal stomatitis .
Thrush .
Oral endamebiasis

II. Nasal Secretion . . ...

General considerations.



Rhinitis



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Pathologic changes . . . ... 44



45



Hay fever . ...... . . 45

Meningitis . . . ... .45

III. Aural Secretion . .• . ■ . 46

General considerations. . 46

Pathologic changes . . _ .5

IV. Conjunctival Secretions .^

General considerations. . . . > .y

Pathologic changes . .... ... 47

Diphtheritic conjunctivitis . . .... 4,7

Infectious conjunctivitis . . .»

Gonorrheal conjunctivitis . . .g

Trachoma .... . .g

Vernal cogp^g^|j^^.^^^^^^@ [[ [ [ ^^



TABLE OF CONTENTS XV

CHAPTER III
Gastric Contents

Page

I. General Considerations 50

II. Methods of Obtaining Gastric Contents 52

Stomach-tube 52

Test meals . 54

Ewald meal . . 54

Boas meal . 55

Riegel meal 55

Fischer meal . . 55

Salzer meal . 56

Sahli meal . . . . 56

III. Macroscopic Examination . 57

Amount . 57

Color . . 58

Odor . . . 59

Consistency . . . 59

Contents from fasting stomach ... 60

Vomitus 60

Contents after test meals . . 61

IV. Microscopic Examination 62

General 62

Pood remnants 62

Boas-Gppler bacillus . . 62

Sarcinas ventriculi 63

Protozoa. .... 63

Tissue fragments 63

Crystals 63

V. Chemical Examination. . 63

General . 64

Total acidity . 64

Free hydrochloric acid . . 65

Qualitative tests 66

Topfer's test . 66

Gunzburg's test . . 66

Boas' test . ... 67

Tropeolin test . . 67

Quantitative tests. 67

Mintz's method 68

Topfer's method . . 68

Amount of free hydrochloric acid 69

Euchlorhydria 70

Hypochlorhydria 70

Ana-chlorhydria . 7°

Hyperchlorhydria 71

Combined hydrochloric acid 71

Method of Martius and Luttke " 71

Method of Topfer 72

Hydrochloric acid deficit .' 73

Organic acids. . 73

Total organic acids 73

Lactic acid-. ........ . ... x„-„«/k\ 74



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Kelling's test. ...

Strauss' method ... .

Butyric acid .

Acetic acid . . .

Gastric ferments . . . .

Pepsin

Qualitative methods 7*

Quantitative examination 79

Hammerschlag's method 79

Mett's method . 79

Method of Thomas and Weber 80

Chymosin . . 81

Leo's method. . . 81

Riegel's method ... 81

Lipase ... 8^

Products of protein digestion 82

Products of carbohydrate digestion 82



Blood . . . . . . .

Gases . . ' ,

Function of the stomach and contents .
VI. Motility of the Stomach

Leube's method . .

Boas' method

Method of Ewald and Sievers .
Winternitz' test . ....

VII. Absorptive Power of the Stomach . . .

Potassium iodide test .

VIII. Indirect Examination of the Stomach Contents ,
Giinzburg's method . . . . .

Sahli's desmoid reaction . . .

IX. Gastric Juice in Disease . .

Hyperchlorhydria . ....

Hypersecretion . . ...

Achylia gastrica

Acute gastritis . . . .

Chronic gastritis

Nervous dyspepsia .

Ulcer of the stomach . .

Carcinoma of the stomach

Salomon's test ... . . . . .

Neubauer and Fischer's test . . . .

Wolff and Junghans' test

CHAPTER IV



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The Feces

I. General Considerations. . .
Normal feces. . .

Diet of Schmidt and Strasburger
DietofPolin. .
Obtaining intestinal juice
Functions of i
Estimation orintestinal"<BgestT6n'



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Page

II. Macroscopic Examination 103

Method 103

Amount 104

Consistency arid form . . 105

Odor 106

Color . . 106

Blood . 108

Mucus . . .. in

Pus . . . 113

Pood remnants . . 113

Protein residues ... . . .114

Pat residues . . 115

Carbohydrate residues . . . '. .116

Biliary constituents . . . 117

Intestinal sand and concretions . 118

Tissue fragments 118

III. Microscopic Examination . . 119

Technic ... 119

Morphological elements , 1 19

Crystals . . . . 120

IV. Chemical Examination. 121

Reaction. . . 121

Total solids 121

Total nitrogen . . . . 122

Fat 123

Carbohydrates . . . 123

Phenoltetrachlorphthalein test ... ... ... 125

V. Bacteriology of the Feces .... . 128

Technic . .... 128

Cholera spirillum .... . 129

Typhoid bacillus 130

Method of Drigalski and Conradi. 130

Method of Kendall and Day 131

Bacillus of Dysentery . 132

Tubercle bacillus ... 132

VI. Parasitology of the Feces . ... 133

Technic 133

Protozoa. 134

Rhizopoda . . 134

Amebina. 134

Ameba coli. . . 134

Entameba coli ... . 137

Sporozoa 137

Coccidium hominis . . 137

Plagellata 137

Trichomonas intestinalis . . . .... 137

Cercomonas hominis 138

Megastoma entericum. X38

Infusoria ... 138

Balantidium coli 138

Entozoa . . ... 139

Platodes . ... .... 139

Cestodes. .... 139

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TABLE OF CONTENTS



Taenia solium . . .
Taenia saginata .
Taenia cucumerina
Taenia nana ....
Taenia diminuta
Taenia echinococcus .
Bothriocephaloidea .

Bothriocephalus latus
Dibothriocephalus cordatus
Bothriocephalus sp. Ijima et Kurimoto
Trematodes
Nematodes .

Ascaridae. . .

Ascaris lumbricoides .
Ascaris mystax .
Oxyuris vermicularis
Angiostomidae . .

Strongyloides intestinalis
Trichotrachelidae .

Trichiuris trichiura
TrichineUa spiralis
Strongylidae

Uncinaria duodenalis
Uncinaria Americana
Pseudo-parasites



CHAPTER V
Parasites



I. General Considerations.
II. Trematodes . .

Pasciolidas

Pasciola hepatica .
Pasciolopsis Buski
Opisthorchis felineus
Opisthorchis sinensis

III. Nematodes

Eustrongylus gigas

IV. Parasites of the Skin.

Arthropoda . .

Arachnoidea . .

Sarcoptes scabiei
Demodex foUiculorum
Leptus autumnalis .
Insecta . . .

Hemiptera . .

Pediculus capitis
Pediculus vestimenti
Pediculus pubis . .
Cimex lectularius . .
Diptera ...
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XIX



Vegetable Parasites

Achorion Schonleinii . .

Trichophyton megalosporon endothrix.

Microsporon Audouini . . . . .

Microsporon furfur . . . . .

Micrdsporon minutissimum . .

Blastomycetes . . .

Sporothrix Schenckii
Negri Bodies



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. 172



CHAPTER VI



The Urine

I. General Considerations. , . .

Collection and preservation .of the urine
II. Physical Properties .

Quantity

Polyuria .

Oliguria

Anuria ... ...

Appearance. .

Color .

Odor. .

Reaction. ...

Folin's method for total acidity .
Free mineral and organic acidity
Specific gravity .
Technic .

Rough estimate of total solids .
Optical activity.
III. Chemical Properties . ...

Normal composition.

Total solids and total ash .
Inorganic constituents .

Chlorids. ....

Estimation of the chlorids
Quantitative determination
Volhard's method . .
Purdy's centrifugal method
Phosphates. ...

Estimation of phosphates
Quantitative determination
Uranium method .
Total phosphoric acid .
Purdy's centrifugal method.
Sulphur compounds . ...

Preformed sulphates
Ethereal sulphates . .
Neutral sulphur .
Estimation of total sulphur
Folin's method .

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TABLE OF CONTENTS



Determination of inorganic sulphates
Purdy's centrifugal method

Carbonates

Sodium and potassium .

Calcium and magnesium

Iron

Organic constituents .
Nitrogenous bodies
Total nitrogen

Kjeldahl's method
Urea ...
Determination of urea.
Knop-Hufner method
Doremus ureometer .
Polin's method .
Morner-Sjoqvist method
Urease method ....
Ammonia .

Quantitative determination
Method of Schlosing
Polin's method .
Formalin method .
Uric acid. .

Quantitative determination ..
Folin's method .
Salkowski-Ludwig method . .
Method of Rudisch and Kleeberg
Ruhemann's method
Purin bases .
Creatinin .

Qualitative tests
Weyl's test.
Jaffa's test .
Quantitative determination .
Polin's methods.
Undetermined nitrogen
Amino acids
Hippuric acid

Oxyproteic and alloxyproteic acids
AUantoin .
Fatty acids .
Oxalic acid .

Quantitative determination .
Baldwin's method. .
Ferments ...
Pepsin .
Diastase .
Lipase .
Mucin-Hke bodies

Mucin. . . . .

Nucleo-albumin . . .
Pigments and, chrqmogens ^^

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TABLE OF CONTENTS XXI

Page

Urobilin 255

Indican ... 256

Tests for indican 257

Jaffa's test 257

Obermayer's test 257

Rosenbach's test . . 258

Quantitative determination . ... .... 259

Wang's method . ... . . . . 259

Polin's method 260

Uroroseinogen 260

Abnormal Composition . . .... 260

Proteins . . 260

Serum-albumin. . 261

Albuminuria 261

Functional. 261

Febrile . . ... 264

Traumatic . . .... 265

Hematogenous . . . . . . 265

Toxic . 265

Neurotic. . . . 265

With definite renal lesions . ... .265

Qualitative tests . . . .... 266

Heat and acid test '. . 267

Heller's nitric acid test . . . 268

Perrocyanide test . . . . . .271

Sulpho-salicylic acid test . . . . . 271

Spiegler's test . . 271

Quantitative methods . ......... . . 272

Scherer's method . . . 272

Esbach's method ... . . 272

Method of Tsuchiya . . . . . 273

Purdy's centrifugal method . . . . 274

Removal of albumin . . . . .274

Serum-globulin . . . 274

Qualitative tests . -275

Quantitative method . ... 276

Proteoses . . .... 276

Primary proteoses ... 276

Bence- Jones' protein . . 276

Secondary proteoses . 278

Tests . . . . . . 279

Bang's method . . . . 279

Clinical significance . . 279

Peptone . ... . . 281

Hemoglobin . . ... .281

Heller's test . . . .282

Donogany's test . . . 282

Fibrin. . ... 283

Carbohydrates 283

Glucose . . .284

Glycosuria . . . 284

Qualitative tests . . . . . 288

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TABLE OF CONTENTS



Benedict's test . . .

Fehling's test. .

Haines' test

Alm^n-Nylander's test

Fermentation test . .

Phenyl-hydrazin test
Quantitative tests . .

Fehling's method

Bang's method .

Purdy's method

Haines' method.

Polariscopic method

Fermentation method

Roberts' method
Levulose. . . .

Levulosuria
Seliwanoff's test
Phenyl-methyl-hydrazin test
Pentose . ...

Pentosuria . . .

QuaUtative tests

Tollen's reaction

Orcin test .
Quantitative test . . .

Diphenyl-hydrazin method
Cammidge's reaction
Lactose . . ...

- Lactosuria

Rubner's test. .
Maltose ...

Maltosuria . .
Glycuronic acid.

Neuberg's quantitative method .
Acetone bodies
Acetone

Qualitative tests

Legal's test

Lieben's test

Gunning's test . .

Frommer's test .
Quantitative methods

Huppert-Messinger method

Polin's method

Diacetic acid .

Qualitative tests

Gerhardt's test .

Arnold's test .

Lipliawsky's test . .
/S-oxybutjrric acid .

Quantitative determination

Black's method. .

Shaffer's method .

AbnorrriSygs^S^^y Microsoft®

Blood pigments .



TABLE OF CONTENTS XXIU

Page

Hemoglobin . . . 328

Hematoporphyrin . . . . 328

Biliary pigments ...... . . . 329

Qualitative tests ... . 329

Smith's test . 33°

Gmelin's test . . 330

Rosenbach's test . . 330

Nakayama's test . . . 330

Hammarsten's test . , • • 33i

Bile acids . 331

Hay's test . . 331

Oliver's test . 332

Melanin . . . . 332

Phenol derivatives . . 332

Alkapton .... . .... 333

Ehrlich's diazo reaction . . . 334

Russo's reaction .... ... 335

Dimethyl-amino-benzaldehyd reaction 336

IV. Microscopic Examination . . 336

Unorganized sediments , . .... 338

Those appearing in acid urine 338

Uric acid . .... 338

Sodium acid urate . . . . . 339

Potassium acid urate . . .... 340

Xanthin. . . .... 341

Calcium oxalate . . 341

Cystin. . . . . 342

Cystinuria . . 342

Leucin. . . 343

Tyrosin . . . . 344

Calcium sulphate . . . 345

Bilirubin 345

Hippuric acid . 345

Neutral calcium phosphate . . 346

Pat . . . . . 346

Chyluria. ... . ... 346

Those appearing in alkaline urine . . ... 347

Ammonium urate . ... 347

Calcium tri-phosphate . . . 347

Magnesium phosphate . . 348

Magnesium-ammonium phosphate 348

Calcium carbonate 349

Organized sediments . 349

Mucoid material . 349

Epithelial cells 349

Pus-cells. . . 351

Pyuria. . 351

VitaU's test . . 353

Donne's test 354

Enumeration of pus-cells . . 354

Red blood-cells . 354

Hematuria. . 354

Casts . . . Digitized by Microsoft® 356

True casts . . . 356



XXIV



TABLE OF CONTENTS



Hyaline casts. .

Granular casts .

Waxy casts . .

Fibrinous casts .

Epithelial casts .

Fatty casts .

Blood-casts .

Pus-casts .

Cylindroids . .

Pseudo-casts .

Cylindruria

Spermatozoa .

Tissue fragments

Bacteria . .

BaciUuria . ,

Parasites ...

V. Calculi

Heller's table for analysis



Online LibraryRalph W. (Ralph Waldo) WebsterDiagnostic methods, chemical, bacteriological and microscopical; a text-book for students and practitioners → online text (page 1 of 97)