WITH the development of powerful and specific agents for the treatment of infections, accurate diagnosis has become increasingly important. It is extremely difficult to handle a patient in diabetic coma without the aid of a chemical laboratory, and it is equally impossible to give satisfactory care to patients with serious infections without the assistance of a good bactériologie laboratory. Consequently, the efforts of the Massachusetts Department of Public Health to improve the quality of bactériologie work throughout the Commonwealth by a system of inspection and approval of laboratories is commended. With these considerations in mind, I shall discuss the present status of diagnostic procedures from the point of view of both the clinician and the laboratory man.
Bacteriologic Procedures
SmearsWith the refinement of laboratory methods, older and simpler tests are often forgotten. This has been true of the practice of examining stained smears of bacteriologic material. As a method of exact diagnosis, a smear has great limitations, but as a guide to the clinician and bacteriologist, it is of inestimable value. It gives a tentative indication of the type of infection in a few minutes, whereas cultures take at least eighteen hours, and it shows the proportions of various types of organisms in mixed infections, as well as the cellular reaction in the exúdate.Smears are particularly useful in the examination of exudates from sites normally sterile, such as serous cavities, the subarachnoid space and tissues. The importance of smear examination in cases of peritonitis and empyema cannot be overemphasized, for cultures from these cases often fail to grow. A discussion of the valuable information yielded by smears of abdominal fluid obtained at laparotomy has recently been published.1 Smears made from sites at which there are normally profuse bacterial flora are difficult to inter-prêt and usually fall to the lot of the medical man. Throat smears are extremely unreliable in the diagnosis of diphtheria and various forms of tonsillitis, and the physician should be guided by his clinical judgment from the appearance of the lesion and by properly taken cultures for confirmation.In pneumonia, the gross inspection of the sputum, in conjunction with examination of a stained smear, may yield valuable information, particularly in such unusual cases as Friedländer's pneumonia.In venereal diseases, smears may be very useful from a man, who normally has an almost sterile urethra, whereas those from the female cervix mean little unless frank pus is seen. Smears of urinary sediment are often more valuable than cultures, when the latter are done by simple broth inoculation. Perhaps the greatest use for smears in medical conditions is in examination of fluid aspirated from acutely inflamed joints, and of cerebrospinal fluid.Certain pitfalls in smear examination are not commonly appreciated. All the gram-positive cocci staphylococcus, pneumococcus and hemolytic streptococcus tend to assume a diplococcal form when growing rapidly in the ...