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ERRORS DUE TO ANTICOAGULANTS
88
SYPHILLTS AND SYPHILIS
single specific problem, somewhat rigid methods are required, because there are
statistical so
many variables. Such studies as those of Donalies in Berlin, and Lendrum in Detroit upon unsuccessful suicide, and the wide surveys of Dublin and Bunzel, Loewenberg and many others show what constant findings a careful statistical treatment yields. Studies of suicide as a particular aspect of depression or some other psychiatric syndrome, or as an expression of fear or hate or death-instinct, according to this or that psychological theory have of course their place, though often they are either too general or too conjectural. The psychological approach must leave unanswered many social and biological problems that are of the first consequence in prophylaxis, and it is possible that at this stage sociological inquiries are likely to be more fruitful than are further psychiatric ones. We know that such things as economic hardship or the " featuring " of suicides in the press contribute to a rise in the suicide rate ; but we can do little as yet to influence these. We know that competent psychiatric diagnosis and treatment can often avert suicide, but we cannot always prevail against public prejudice in regard to such treatment, especially if it is to be in an institution ; and at the moment concentration on propaganda for mental hygiene and improvement of social condition is needed more than inquiry into
the individual miseries which to end life.
precede
the decision
ERRORS DUE TO ANTICOAGULANTS
that the anticoagulants in general in blood analyses has been suspected for some time. I. Blitsteinhas now made a careful study of the variations which may be pro,duced in this way. He has investigated the influence of potassium oxalate, sodium citrate, sodium fluoride, zinc sulphate, heparin, hirudin, and a proprietary anticoagulant called Liquoide (sodium polyanethylsulphonate) on the following estimations: inorganic THE
use
possibility
may
cause
errors
phosphorus, plasma proteins, chlorides, cholesterol, dry extract, and hsematocrit. There are, he finds, two sources of error. First, the plasma becomes more dilute owing to water leaving the erythrocytes ; this is dependent upon the increase in ionic concentration of the plasma due to the added anticoagulant. This
effect is constant for the first four substances investigated and is in proportion to the quantity of the substance used. The second effect is more marked with fluoride and oxalate than with citrate and sulphate, and is due to the toxic action which these salts exert upon the envelope of the erythrocyte, whereby it loses the properties of a semi-permeable membrane and allows some of its contents to diffuse out into the plasma. The author concludes that these four anticoagulants should be discarded and that hirudin, heparin, or liquoide be employed in estimations of hoematocrit, dry extract, chlorides, and cholesterol. In determination of inorganic phosphorus, he holds, liquoide only should be used as heparin contains traces of phosphorus and hirudin disturbs the colorimetric comparison. For plasma proteins, he believes that fibrinogen should be estimated by the refractometric method of W. Starlinger 2 and albumin and globulin from the serum. The interest in this paper lies in the conclusion that the anticoagulants in common use are those most apt to produce errors in estimations. Perhaps the point of greatest practical significance is that the haematocrit varies over a wide 1 Rev. Beige des Sci. med., 1935, vii., 69. 2 Biochem. Zeitschr., 1923, cxliii., 179.
range with the four interdicted substances but is constant with the three others. The two blood analyses most
helpful
to
clinicians-blood-sugar and study.
blood-
urea-have not been considered in this
THE ROYAL SURGICAL AID SOCIETY
THE annual report of the Royal Surgical Aid Society for this year has just appeared and the record of the work done shows that the society is living up to the high standard of practical utility which it has manifested since its start. And that is a considerable period, for it was established in 1862 at a time when no institution existed through which the needy patient could obtain much choice of the required surgical appliances. Many institutions did, and still do, largely assist discharged patients to obtain orthopaedic appliances, this being particularly the case when an instrument of a certain sort was needed to maintain the improvement manifested and lead to further progress. But three-quarters of a century ago it was seen that such assistance was only applicable to the fringe of the manifest needs, and to-day, with the enormous growth of these needs, the value of the ’central organisation is more than ever obvious. The records in the annual report demonstrate how extensive and various are the wants of the applicants, and over 29,000 cases have had those wants supplied during the year under review. The charitable public has responded well throughout the history of the society, enabling it to continue its mission, but the committee appeal for more liberal support during the coming year, since there has been a slight falling off of income which does not accord with a certain abatement of general financial stringency. But while there has been a decrease in special donations in aid of cases, the payments received from patients themselves show a gratifying increase, while the cost of administration has remained almost stationary. Accompanying the report there is an appeal for the constitution of a special fund to be devoted to the relief of cases in the Durham district. The demands from the distressed areas, Durham being taken as a centre, have increased to such an extent that the committee of the society do not feel justified in meeting them from the ordinary resources. There are, it seems, practically no subscribers to the society in the Durham district, and conditions being as they are it is obvious that assistance will have to be found from outside. Therefore the society is making a special appeal for the raising of a fund of at least i3000 in order to cope with this urgent situation, pointing out that if funds are forthcoming, enabling them to deal with the cases locally, a more direct control of the assistance will be created and trouble and postage saved on Support in many fruitless applications by letter. aid of this special appeal should be sent to the Royal Surgical Aid Society, Salisbury-square, London, E.C. SYPHILUS AND SYPHILIS
IT is given to few men to achieve immortality by the expedient of inventing a single word. Such an unwonted survival has fallen to the lot of the poetphysician Fracastor, and in a fashion all the more curious because the fateful word occurs only in a somewhat uneasy addition to his poem as first written and finally taken as a part title for the extended work-Syphilis sive Morbus GaZlicus. In this appended Book III, Fracastor relates how a certain shepherd, Syphilus by name, provoked Apollo by his impiety, and as punishment was smitten by a new disease which from this the name of its first victim his fellow countrymen called " syphilis." In a recent issue cf
SYPHILLTS AND SYPHILIS
single specific problem, somewhat rigid methods are required, because there are
statistical so
many variables. Such studies as those of Donalies in Berlin, and Lendrum in Detroit upon unsuccessful suicide, and the wide surveys of Dublin and Bunzel, Loewenberg and many others show what constant findings a careful statistical treatment yields. Studies of suicide as a particular aspect of depression or some other psychiatric syndrome, or as an expression of fear or hate or death-instinct, according to this or that psychological theory have of course their place, though often they are either too general or too conjectural. The psychological approach must leave unanswered many social and biological problems that are of the first consequence in prophylaxis, and it is possible that at this stage sociological inquiries are likely to be more fruitful than are further psychiatric ones. We know that such things as economic hardship or the " featuring " of suicides in the press contribute to a rise in the suicide rate ; but we can do little as yet to influence these. We know that competent psychiatric diagnosis and treatment can often avert suicide, but we cannot always prevail against public prejudice in regard to such treatment, especially if it is to be in an institution ; and at the moment concentration on propaganda for mental hygiene and improvement of social condition is needed more than inquiry into
the individual miseries which to end life.
precede
the decision
ERRORS DUE TO ANTICOAGULANTS
that the anticoagulants in general in blood analyses has been suspected for some time. I. Blitsteinhas now made a careful study of the variations which may be pro,duced in this way. He has investigated the influence of potassium oxalate, sodium citrate, sodium fluoride, zinc sulphate, heparin, hirudin, and a proprietary anticoagulant called Liquoide (sodium polyanethylsulphonate) on the following estimations: inorganic THE
use
possibility
may
cause
errors
phosphorus, plasma proteins, chlorides, cholesterol, dry extract, and hsematocrit. There are, he finds, two sources of error. First, the plasma becomes more dilute owing to water leaving the erythrocytes ; this is dependent upon the increase in ionic concentration of the plasma due to the added anticoagulant. This
effect is constant for the first four substances investigated and is in proportion to the quantity of the substance used. The second effect is more marked with fluoride and oxalate than with citrate and sulphate, and is due to the toxic action which these salts exert upon the envelope of the erythrocyte, whereby it loses the properties of a semi-permeable membrane and allows some of its contents to diffuse out into the plasma. The author concludes that these four anticoagulants should be discarded and that hirudin, heparin, or liquoide be employed in estimations of hoematocrit, dry extract, chlorides, and cholesterol. In determination of inorganic phosphorus, he holds, liquoide only should be used as heparin contains traces of phosphorus and hirudin disturbs the colorimetric comparison. For plasma proteins, he believes that fibrinogen should be estimated by the refractometric method of W. Starlinger 2 and albumin and globulin from the serum. The interest in this paper lies in the conclusion that the anticoagulants in common use are those most apt to produce errors in estimations. Perhaps the point of greatest practical significance is that the haematocrit varies over a wide 1 Rev. Beige des Sci. med., 1935, vii., 69. 2 Biochem. Zeitschr., 1923, cxliii., 179.
range with the four interdicted substances but is constant with the three others. The two blood analyses most
helpful
to
clinicians-blood-sugar and study.
blood-
urea-have not been considered in this
THE ROYAL SURGICAL AID SOCIETY
THE annual report of the Royal Surgical Aid Society for this year has just appeared and the record of the work done shows that the society is living up to the high standard of practical utility which it has manifested since its start. And that is a considerable period, for it was established in 1862 at a time when no institution existed through which the needy patient could obtain much choice of the required surgical appliances. Many institutions did, and still do, largely assist discharged patients to obtain orthopaedic appliances, this being particularly the case when an instrument of a certain sort was needed to maintain the improvement manifested and lead to further progress. But three-quarters of a century ago it was seen that such assistance was only applicable to the fringe of the manifest needs, and to-day, with the enormous growth of these needs, the value of the ’central organisation is more than ever obvious. The records in the annual report demonstrate how extensive and various are the wants of the applicants, and over 29,000 cases have had those wants supplied during the year under review. The charitable public has responded well throughout the history of the society, enabling it to continue its mission, but the committee appeal for more liberal support during the coming year, since there has been a slight falling off of income which does not accord with a certain abatement of general financial stringency. But while there has been a decrease in special donations in aid of cases, the payments received from patients themselves show a gratifying increase, while the cost of administration has remained almost stationary. Accompanying the report there is an appeal for the constitution of a special fund to be devoted to the relief of cases in the Durham district. The demands from the distressed areas, Durham being taken as a centre, have increased to such an extent that the committee of the society do not feel justified in meeting them from the ordinary resources. There are, it seems, practically no subscribers to the society in the Durham district, and conditions being as they are it is obvious that assistance will have to be found from outside. Therefore the society is making a special appeal for the raising of a fund of at least i3000 in order to cope with this urgent situation, pointing out that if funds are forthcoming, enabling them to deal with the cases locally, a more direct control of the assistance will be created and trouble and postage saved on Support in many fruitless applications by letter. aid of this special appeal should be sent to the Royal Surgical Aid Society, Salisbury-square, London, E.C. SYPHILUS AND SYPHILIS
IT is given to few men to achieve immortality by the expedient of inventing a single word. Such an unwonted survival has fallen to the lot of the poetphysician Fracastor, and in a fashion all the more curious because the fateful word occurs only in a somewhat uneasy addition to his poem as first written and finally taken as a part title for the extended work-Syphilis sive Morbus GaZlicus. In this appended Book III, Fracastor relates how a certain shepherd, Syphilus by name, provoked Apollo by his impiety, and as punishment was smitten by a new disease which from this the name of its first victim his fellow countrymen called " syphilis." In a recent issue cf