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DISCREPANCIES IN THE ERYTHROGYTE-SEDIMENTATION TEST
431 now no indication in the treatment of
arsenical therapy, consider that there is for the
use
of these
dangerous drugs
svohilis. Whitechapel Clinic, London Hospital, E.1.
J. K. OATES.
"
ANTIMALARIALS AND RHEUMATOID
SiR,—Dr
Ray Bettley (Feb. 9)
are
to
attention to chronic leg congratulated ulceration in rheumatoid arthritis and suggesting that perhaps this association is not rare. They show understandable caution in their interpretation of the finding of L.E. cells in 4 of their 6 patients who otherwise would have been regarded simply as suffering from long-standing rheumatoid arthritis, with rheumatoid nodules and crippling deformities to substantiate the diagnosis. Pathologists now have sufficient experience to enable them to identify L.E. cells which would be acceptable as such to their colleagues. The significance of this cell is now being freely discussed between them and clinicians ; is the cell specific to lupus erythematosus or not ? While this controversy is pursued, I must point out that patients with rheumatoid arthritis are being crippled now. Clinicians accept the value of chloroquine and certain other antimalarials in disseminated lupus erythematosus. I urge them to try these drugs in rheumatoid arthritis. I have shown that they are of value in a short-term controlled investigation1 and am to establish their long-term value, of which I am convinced on clinical grounds. be
on
drawing
our
endeavouring
Hackney Hospital, London, E.9.
A. FREEDMAN. discuss Dr. Freedman’s trial of chloroquine in We %* an annotation on p. 414.-ED. L. ERYTHROCYTE-POTASSIUM LEVELS IN RHEUMATOID ARTHRITIS
interested to read the preliminary communication by Dr. Knudsen and Mr. Thomas (Feb. 2). We are carrying out a similar investigation here in connection with the use of adrenal corticoids in chest disease. Our method is likewise to calculate the erythrocyte-potassium level from the whole-blood-potassium and the haematocrit value, using heparinised venous blood and undertaking the estimations with as little delay as possible, although with different dilutions (1 in 500 for whole-blood-potassium and 1 in 50 for plasma-potassium samples). The group we have analysed so far consists of patients with pulmonary tuberculosis, who are symptom-free but are receiving chemotherapy. 69 estimations have been made in this group, with a mean erythrocyte-potassium level of 105 m.eq. per litre. The distribution of values around the mean fits very closely the pattern of a normal (Gaussian) curve, with a standard deviation of 5 m.eq. per litre. We have to date found a negative correlation between the erythrocytepotassium levels and hsematocrit readings (r = -0-57) We are also investigating a normal control group, consisting of hospital staff, and patients with chest disease who are receiving adrenal corticoids.
SiR,-I
headache. Because of dizziness, which persisted for up to three days, the patients scarcely dared to turn the head. A few patients had a mild relapse after six or seven days. The incubation period was probably seven days. eyes " and very
ARTHRITIS
Allison and Dr.
The illness was principally characterised by sudden onset, vomiting, extremely severe headache, vertigo, meningism, temperature up to 38-5°C, absence of any other complications, and rapid recovery. A lumbar puncture in a 5-year-old girl with a definite Kernig’s sign and absent knee-jerks showed 21 cells per c.mm., 28 mg. protein per 100 ml., and no organisms. Adults particularly complained of pressure behind the severe
We, too, were unable to detect the causal agent. In the same year cases of West Nile fever were reported in Israel. Investigation was made in this direction, but with negative results. A. KALLNER. DISCREPANCIES IN THE ERYTHROGYTESEDIMENTATION TEST SiR,-The discrepancies in the E.s.R. test in rheumatic fever found by Dr. Alexander and Mr. Andrews (Feb. 2) have been fully described by, among others, Enocksson et al., Wilander,2Strom,3 von Kaulla,4 Nielsen,5 and Oestner.6 I found the same phenomenon during a study of the E.s.R. in defibrinated and undiluted blood.7
Oestner
explains
its
occurrence as
follows :
In undiluted blood, in which the content of fibrinogen, globulin, and erythrocytes is greater than in diluted blood, particularly when the absolute values of protein are high, such large aggregates of erythrocytes are formed that these can close off completely the lumen of the sedimentation tube. The sedimentation process is thus impeded, Sometimes, when an aggregate breaks loose, sedimentation can then continue, giving rise to characteristic forms in the sedimentation curve,
which
are
not found when diluted blood is used.
Naturally this phenomenon particular disease.
is not
specific
to any
A. S. GROEN.
was
Clare Hall Hospital, South Mimms, Barnet.
S. GILLIS.
" WINTER VOMITING DISEASE ’
SiR,—I read the paper by Dr. Haworth and his col-
leagueswith great interest my own experience.33
and would like to refer to
S]IR,-SeyffertiI reported the results of treating disseminated sclerosis with phenothiazine derivatives. The effect in the chronic cases was good ; spastic symptoms I have compared the effects of were especially relieved. a similar derivative, ’Lacumin’ (n-methylpiperidyl-3methylphenothiazine), with those of a placebo in 90 patients suffering from the disease. ’
There
and 57 women, aged 24-64 years (mean they had all belonged to a special disseminated-sclerosis society in Gothenburg. The diagnosis was established by examinations at the neurological clinic in 54 cases. The others had previously been examined at outpatient departments by neurologists or in connection with the present investigation. The duration of the disease varied between 2 and 30 years (mean 9-4). The degree of disability varied from slight dysfunction (slight weakness and disturbances of gait, mild eye symptoms) to pronounced disturbances of gait and inability to move except in a wheel-chair. Most patients needed crutches. All had been told about the nature of their disease. Most had tried various remedies. As a rule the patients kept in touch with each other, and had meetings once a month. At first lacumin was given to one group of patients. Aftertime a rumour circulated that these tablets had some unpleasant side-effects. The placebo (which was called ’Lacumin P ’) was then introduced as a drug which had exactly the same effect as the lacumin tablets, but no sideeffects. At the same time it was pointed out that the side-
40-2).
caffarte
In an agricultural settlement, with a population of 1400, 102 cases occurred during the three summer months of 1954 ; 83 of the patients were children up to 16 years of age, and the age-group particularly involved was the 3-6-year-olds. 1. Ann. rheum. Dis. 1956, 15, 251. 2. Haworth, J. C., Tyrrell, D. A. J., Whitehead, J. 1956, ii, 1152. 3. Kallner, A. Harefuah, Aug. 15, 1954.
TREATMENT OF DISSEMINATED SCLEROSIS WITH ACTIVE AND INACTIVE DRUGS
E. M.
Lancet,
1.
were
33
men
For several years
were
mnt, carinmc Q
Enocksson, B., Gjertz, A., Schnell, A., Torgensrund, med. scand. 1936, 88, 455. 2. Wilander, O. Ibid, 1938, 94, 258. 3. Ström, J. Ibid, 1938, 96, 365. 4. von Kaulla, K. N. Ibid, 1939, 98, 374. 5. Nielsen, G. Ibid, 1942, 111, 66. 6. Oestner, K. Ibid, 1942, suppl. 127. 7. Thesis Amsterdam 1953. 8. Seyffert, H.-M. Münch, med. Wschr. 1955, 97, 1623.
T.
Acta.
arsenical therapy, consider that there is for the
use
of these
dangerous drugs
svohilis. Whitechapel Clinic, London Hospital, E.1.
J. K. OATES.
"
ANTIMALARIALS AND RHEUMATOID
SiR,—Dr
Ray Bettley (Feb. 9)
are
to
attention to chronic leg congratulated ulceration in rheumatoid arthritis and suggesting that perhaps this association is not rare. They show understandable caution in their interpretation of the finding of L.E. cells in 4 of their 6 patients who otherwise would have been regarded simply as suffering from long-standing rheumatoid arthritis, with rheumatoid nodules and crippling deformities to substantiate the diagnosis. Pathologists now have sufficient experience to enable them to identify L.E. cells which would be acceptable as such to their colleagues. The significance of this cell is now being freely discussed between them and clinicians ; is the cell specific to lupus erythematosus or not ? While this controversy is pursued, I must point out that patients with rheumatoid arthritis are being crippled now. Clinicians accept the value of chloroquine and certain other antimalarials in disseminated lupus erythematosus. I urge them to try these drugs in rheumatoid arthritis. I have shown that they are of value in a short-term controlled investigation1 and am to establish their long-term value, of which I am convinced on clinical grounds. be
on
drawing
our
endeavouring
Hackney Hospital, London, E.9.
A. FREEDMAN. discuss Dr. Freedman’s trial of chloroquine in We %* an annotation on p. 414.-ED. L. ERYTHROCYTE-POTASSIUM LEVELS IN RHEUMATOID ARTHRITIS
interested to read the preliminary communication by Dr. Knudsen and Mr. Thomas (Feb. 2). We are carrying out a similar investigation here in connection with the use of adrenal corticoids in chest disease. Our method is likewise to calculate the erythrocyte-potassium level from the whole-blood-potassium and the haematocrit value, using heparinised venous blood and undertaking the estimations with as little delay as possible, although with different dilutions (1 in 500 for whole-blood-potassium and 1 in 50 for plasma-potassium samples). The group we have analysed so far consists of patients with pulmonary tuberculosis, who are symptom-free but are receiving chemotherapy. 69 estimations have been made in this group, with a mean erythrocyte-potassium level of 105 m.eq. per litre. The distribution of values around the mean fits very closely the pattern of a normal (Gaussian) curve, with a standard deviation of 5 m.eq. per litre. We have to date found a negative correlation between the erythrocytepotassium levels and hsematocrit readings (r = -0-57) We are also investigating a normal control group, consisting of hospital staff, and patients with chest disease who are receiving adrenal corticoids.
SiR,-I
headache. Because of dizziness, which persisted for up to three days, the patients scarcely dared to turn the head. A few patients had a mild relapse after six or seven days. The incubation period was probably seven days. eyes " and very
ARTHRITIS
Allison and Dr.
The illness was principally characterised by sudden onset, vomiting, extremely severe headache, vertigo, meningism, temperature up to 38-5°C, absence of any other complications, and rapid recovery. A lumbar puncture in a 5-year-old girl with a definite Kernig’s sign and absent knee-jerks showed 21 cells per c.mm., 28 mg. protein per 100 ml., and no organisms. Adults particularly complained of pressure behind the severe
We, too, were unable to detect the causal agent. In the same year cases of West Nile fever were reported in Israel. Investigation was made in this direction, but with negative results. A. KALLNER. DISCREPANCIES IN THE ERYTHROGYTESEDIMENTATION TEST SiR,-The discrepancies in the E.s.R. test in rheumatic fever found by Dr. Alexander and Mr. Andrews (Feb. 2) have been fully described by, among others, Enocksson et al., Wilander,2Strom,3 von Kaulla,4 Nielsen,5 and Oestner.6 I found the same phenomenon during a study of the E.s.R. in defibrinated and undiluted blood.7
Oestner
explains
its
occurrence as
follows :
In undiluted blood, in which the content of fibrinogen, globulin, and erythrocytes is greater than in diluted blood, particularly when the absolute values of protein are high, such large aggregates of erythrocytes are formed that these can close off completely the lumen of the sedimentation tube. The sedimentation process is thus impeded, Sometimes, when an aggregate breaks loose, sedimentation can then continue, giving rise to characteristic forms in the sedimentation curve,
which
are
not found when diluted blood is used.
Naturally this phenomenon particular disease.
is not
specific
to any
A. S. GROEN.
was
Clare Hall Hospital, South Mimms, Barnet.
S. GILLIS.
" WINTER VOMITING DISEASE ’
SiR,—I read the paper by Dr. Haworth and his col-
leagueswith great interest my own experience.33
and would like to refer to
S]IR,-SeyffertiI reported the results of treating disseminated sclerosis with phenothiazine derivatives. The effect in the chronic cases was good ; spastic symptoms I have compared the effects of were especially relieved. a similar derivative, ’Lacumin’ (n-methylpiperidyl-3methylphenothiazine), with those of a placebo in 90 patients suffering from the disease. ’
There
and 57 women, aged 24-64 years (mean they had all belonged to a special disseminated-sclerosis society in Gothenburg. The diagnosis was established by examinations at the neurological clinic in 54 cases. The others had previously been examined at outpatient departments by neurologists or in connection with the present investigation. The duration of the disease varied between 2 and 30 years (mean 9-4). The degree of disability varied from slight dysfunction (slight weakness and disturbances of gait, mild eye symptoms) to pronounced disturbances of gait and inability to move except in a wheel-chair. Most patients needed crutches. All had been told about the nature of their disease. Most had tried various remedies. As a rule the patients kept in touch with each other, and had meetings once a month. At first lacumin was given to one group of patients. Aftertime a rumour circulated that these tablets had some unpleasant side-effects. The placebo (which was called ’Lacumin P ’) was then introduced as a drug which had exactly the same effect as the lacumin tablets, but no sideeffects. At the same time it was pointed out that the side-
40-2).
caffarte
In an agricultural settlement, with a population of 1400, 102 cases occurred during the three summer months of 1954 ; 83 of the patients were children up to 16 years of age, and the age-group particularly involved was the 3-6-year-olds. 1. Ann. rheum. Dis. 1956, 15, 251. 2. Haworth, J. C., Tyrrell, D. A. J., Whitehead, J. 1956, ii, 1152. 3. Kallner, A. Harefuah, Aug. 15, 1954.
TREATMENT OF DISSEMINATED SCLEROSIS WITH ACTIVE AND INACTIVE DRUGS
E. M.
Lancet,
1.
were
33
men
For several years
were
mnt, carinmc Q
Enocksson, B., Gjertz, A., Schnell, A., Torgensrund, med. scand. 1936, 88, 455. 2. Wilander, O. Ibid, 1938, 94, 258. 3. Ström, J. Ibid, 1938, 96, 365. 4. von Kaulla, K. N. Ibid, 1939, 98, 374. 5. Nielsen, G. Ibid, 1942, 111, 66. 6. Oestner, K. Ibid, 1942, suppl. 127. 7. Thesis Amsterdam 1953. 8. Seyffert, H.-M. Münch, med. Wschr. 1955, 97, 1623.
T.
Acta.