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THE RED CELL SEDIMENTATION TEST.
343
subsequent or associated endocarditis, and somez, of his descriptions of the architecture of the lesions I, suggest that the primary lesion of the rheumatic ’, virus, wherever it occurs, shows a strong tendency to ’i heal. On the other hand, in the case described, the tricuspid valve showed abundant microscopic evidence of valvulitis but none of endocarditis, and the inference is that in many cases the valves of the right side of the heart in rheumatic fever are the site of valvulitis without clinical or macroscopic evidence of frank endocarditis. Dr. J. Purdon Martin, in our columns last year,! showed in a case of chorea a sharply defined vascular lesion at the base of the brain in the body of Luys. This structure is subjacent to the thalamus and is probably in contact with both cerebellar and pyramidal fibres. In Dr. Martin’s case the lesion caused an illness indistinguishable in many respect from rheumatic chorea, and he therefore indicated the body of Luys as a probable site for focal rheumatic infection in ordinary common chorea. Dr. Bernard Shaw found no adequate anatomical bases for the chorea in any part of the brain. ____
THE RED CELL SEDIMENTATION TEST. THE red cell sedimentation test has found but popularity in England and is far less generally
little
used here than abroad. This is perhaps fortunate since our knowledge of its significance in clinical medicine is still far from complete. Nevertheless, the subject now has a large literature, and there is no doubt that the test offers us aid in diagnosis and prognosis that can no longer be ignored. The two methods employed in carrying it out are very simple, and the minimum of apparatus needed is easily available for every practitioner. Both depend upon the rate at which the red cells sink in citrated blood on standing, and they differ only in the way in which results are recorded and in minor details of technique. Numerous modifications of these methods, which are associated with the names of Fahraeus, Linzenmeier, and Westergren, have been proposed, and results are usually given either in terms of the time taken for the deposit of red cells to reach a given height, or in terms of the height reached by the column in a given interval of time. The diversity of the standards used by different workers and the variation in method have made it difficult to compare results, and have undoubtedly been partly responsible for the disrepute in which the test is held by many. Whichever method is adopted, all are agreed that normal healthy persons show a high suspension stability of the blood, which is to say, that the separation of red cells and plasma is slow. What this depends upon is not fully understood, and probably no single physico-chemical2 mechanism is entirely responsible. Prof. F. Reiche has lately studied the relationship of the sedimentationrate to some of the chemical constituents present in the blood, and to some of its physical properties time and bleeding time. His such as the coagulation investigations have been performed upon over 4000 patients, and include estimations of almost all the important substances that may be quantitatively determined in the serum and in blood. He could, however, find no one factor that could be causally related to alterations in the rate of sedimentation. This did not, for instance, depend upon the number of red or white cells present, nor upon the haemoglobin percentage, nor upon the clotting power of the blood. Nor could Reiche confirm the suggestion that the protein content of the serum was the important factor, for variations in fibrinogen and albuminglobulin ratios were present with independent variations in sinking time. The number of platelets has also been thought to affect the rate of sedimentation, as has the size of the red cells as apart from their numbers ; but apparently neither is in fact causally 1 A Contribution to the Study of
1928, ii., 315.
2
Chorea, THE LANCET,
Med. Klin., 1929, xxiii., 899.
concerned.
The
cholesterin,
sugar,
amounts of chloride, calcium, and non-protein nitrogen were found to be independent of the suspension power of
the blood. An examination so thorough should command respect, and it must be confessed that at present no one knows what are the essential changes in the blood which increase the speed of sedimentation, or what are the factors which maintain its normal suspension stability. Despite this ignorance, however, certain general conclusions may justifiably be drawn from practical experience, and they are none the less valuable for an absence of explanation of these results. Thus it may be stated that abnormally rapid sedimentation of the red cells is always associated with organic disease and excludes a purely functional disorder. This alone is a help in differential diagnosis, for example, in neurasthenia and early phthisis. The most strongly positive results (i.e., the most rapid sinking) are usually found in those conditions in which tissue destruction, autolysis, and absorption of breakdown products are occurring ; and may thus to some extent separate purulent from non-purulent, and acute from chronic inflammations. Negative results are of less significance in excluding such conditions; thus a normal reaction is occasionally noted in even advanced organic disease, and may sometimes be recorded in severe pulmonary tuberclea condition in which the test has been widely applied as an aid to prognosis. On the other hand, positive results are very seldom seen in the absence of such disorders, except in the first two to three months of pregnancy. For the diagnosis of carcinoma the test is valueless. As a guide to the existence of latent toxaemia from the presence of a septic focus, and in the exclusion of purely neurotic conditions-a positive result is of considerable significance. As an index of the progress of cases of both acute and chronic infections, notably in phthisis, the gradual return to normal of the sedimentation time of the red cells is of definite value. Many exaggerated claims have been made for its specific relationship to individual diseases, but within limitations this simple test seems to have its uses.
I
ASSISTED ALPINE CURES. THE Queen Alexandra Sanatorium Fund, of which the annual report for 1928-29 has just been issued, made it possible last winter for 52 men and women to make a prolonged stay at Davos, when apart from such help they would not have been able to do so. For the last four seasons the practice has been to make block grants of 22 (50 francs) a week, allowing patients to choose their own accommodation from a list of approved establishments ; and this grant scheme has worked well in practice, those who have been assisted by the Fund having recognised the responsibility which such a trust implies. Only two complaints were received from the visiting physicians in Davos, and one patient who was described by her medical attendant as " a happy-go-lucky young woman " nevertheless did extremely well. The Fund which gives these grants is the product of the sale of the Queen Alexandra Sanatorium which was built in. Davos for British patients of small means some years before the war. As it proved impossible to reopen the sanatorium after the war at a fee within the reach of the class of patient for whom it had been intended, the Council of the Fund was faced with the alternative of altering the whole character of the institution, or of selling the building and devoting the proceeds to helping patients of small means to get treatment in Alpine climate in some other manner. The ordinary income of the Fund is about 22000 a year and it has recently been augmented by amalgamation with the St. Moritz Aid Fund, a smaller though similar organisation with its former seat in the Engadine. Last winter the assisted patients included two medical practitioners, two dentists, six students, three nurses, and many other professional persons. The average stay was 168 days and the
subsequent or associated endocarditis, and somez, of his descriptions of the architecture of the lesions I, suggest that the primary lesion of the rheumatic ’, virus, wherever it occurs, shows a strong tendency to ’i heal. On the other hand, in the case described, the tricuspid valve showed abundant microscopic evidence of valvulitis but none of endocarditis, and the inference is that in many cases the valves of the right side of the heart in rheumatic fever are the site of valvulitis without clinical or macroscopic evidence of frank endocarditis. Dr. J. Purdon Martin, in our columns last year,! showed in a case of chorea a sharply defined vascular lesion at the base of the brain in the body of Luys. This structure is subjacent to the thalamus and is probably in contact with both cerebellar and pyramidal fibres. In Dr. Martin’s case the lesion caused an illness indistinguishable in many respect from rheumatic chorea, and he therefore indicated the body of Luys as a probable site for focal rheumatic infection in ordinary common chorea. Dr. Bernard Shaw found no adequate anatomical bases for the chorea in any part of the brain. ____
THE RED CELL SEDIMENTATION TEST. THE red cell sedimentation test has found but popularity in England and is far less generally
little
used here than abroad. This is perhaps fortunate since our knowledge of its significance in clinical medicine is still far from complete. Nevertheless, the subject now has a large literature, and there is no doubt that the test offers us aid in diagnosis and prognosis that can no longer be ignored. The two methods employed in carrying it out are very simple, and the minimum of apparatus needed is easily available for every practitioner. Both depend upon the rate at which the red cells sink in citrated blood on standing, and they differ only in the way in which results are recorded and in minor details of technique. Numerous modifications of these methods, which are associated with the names of Fahraeus, Linzenmeier, and Westergren, have been proposed, and results are usually given either in terms of the time taken for the deposit of red cells to reach a given height, or in terms of the height reached by the column in a given interval of time. The diversity of the standards used by different workers and the variation in method have made it difficult to compare results, and have undoubtedly been partly responsible for the disrepute in which the test is held by many. Whichever method is adopted, all are agreed that normal healthy persons show a high suspension stability of the blood, which is to say, that the separation of red cells and plasma is slow. What this depends upon is not fully understood, and probably no single physico-chemical2 mechanism is entirely responsible. Prof. F. Reiche has lately studied the relationship of the sedimentationrate to some of the chemical constituents present in the blood, and to some of its physical properties time and bleeding time. His such as the coagulation investigations have been performed upon over 4000 patients, and include estimations of almost all the important substances that may be quantitatively determined in the serum and in blood. He could, however, find no one factor that could be causally related to alterations in the rate of sedimentation. This did not, for instance, depend upon the number of red or white cells present, nor upon the haemoglobin percentage, nor upon the clotting power of the blood. Nor could Reiche confirm the suggestion that the protein content of the serum was the important factor, for variations in fibrinogen and albuminglobulin ratios were present with independent variations in sinking time. The number of platelets has also been thought to affect the rate of sedimentation, as has the size of the red cells as apart from their numbers ; but apparently neither is in fact causally 1 A Contribution to the Study of
1928, ii., 315.
2
Chorea, THE LANCET,
Med. Klin., 1929, xxiii., 899.
concerned.
The
cholesterin,
sugar,
amounts of chloride, calcium, and non-protein nitrogen were found to be independent of the suspension power of
the blood. An examination so thorough should command respect, and it must be confessed that at present no one knows what are the essential changes in the blood which increase the speed of sedimentation, or what are the factors which maintain its normal suspension stability. Despite this ignorance, however, certain general conclusions may justifiably be drawn from practical experience, and they are none the less valuable for an absence of explanation of these results. Thus it may be stated that abnormally rapid sedimentation of the red cells is always associated with organic disease and excludes a purely functional disorder. This alone is a help in differential diagnosis, for example, in neurasthenia and early phthisis. The most strongly positive results (i.e., the most rapid sinking) are usually found in those conditions in which tissue destruction, autolysis, and absorption of breakdown products are occurring ; and may thus to some extent separate purulent from non-purulent, and acute from chronic inflammations. Negative results are of less significance in excluding such conditions; thus a normal reaction is occasionally noted in even advanced organic disease, and may sometimes be recorded in severe pulmonary tuberclea condition in which the test has been widely applied as an aid to prognosis. On the other hand, positive results are very seldom seen in the absence of such disorders, except in the first two to three months of pregnancy. For the diagnosis of carcinoma the test is valueless. As a guide to the existence of latent toxaemia from the presence of a septic focus, and in the exclusion of purely neurotic conditions-a positive result is of considerable significance. As an index of the progress of cases of both acute and chronic infections, notably in phthisis, the gradual return to normal of the sedimentation time of the red cells is of definite value. Many exaggerated claims have been made for its specific relationship to individual diseases, but within limitations this simple test seems to have its uses.
I
ASSISTED ALPINE CURES. THE Queen Alexandra Sanatorium Fund, of which the annual report for 1928-29 has just been issued, made it possible last winter for 52 men and women to make a prolonged stay at Davos, when apart from such help they would not have been able to do so. For the last four seasons the practice has been to make block grants of 22 (50 francs) a week, allowing patients to choose their own accommodation from a list of approved establishments ; and this grant scheme has worked well in practice, those who have been assisted by the Fund having recognised the responsibility which such a trust implies. Only two complaints were received from the visiting physicians in Davos, and one patient who was described by her medical attendant as " a happy-go-lucky young woman " nevertheless did extremely well. The Fund which gives these grants is the product of the sale of the Queen Alexandra Sanatorium which was built in. Davos for British patients of small means some years before the war. As it proved impossible to reopen the sanatorium after the war at a fee within the reach of the class of patient for whom it had been intended, the Council of the Fund was faced with the alternative of altering the whole character of the institution, or of selling the building and devoting the proceeds to helping patients of small means to get treatment in Alpine climate in some other manner. The ordinary income of the Fund is about 22000 a year and it has recently been augmented by amalgamation with the St. Moritz Aid Fund, a smaller though similar organisation with its former seat in the Engadine. Last winter the assisted patients included two medical practitioners, two dentists, six students, three nurses, and many other professional persons. The average stay was 168 days and the