5
GOLOB AND BOROWSKY--VALUE OF A ROUTINE RED CELL SEDIMENTATION TEST IN GASTRO-ENTEROLOGY 387 emphatically that these men are among the greatest benefactors of mankind. As regards the dosage, no fixed rules can be laid down. It is impossible to say whether 100 or 200-300 units a day will be required. It depends entirely on the individual. I had patients who felt well when taking 100 units a day and others when taking 700 (seven hundred) units a day. The proper daily dose for the patient is that quantity of hormone on which he gains weight. It varies greatly. Sometimes the increase in body weight begins late, but an improve- meat soon appears in the gastric symptoms, while the appetite and muscular strength increase; this improve- ment is accompanied'by a subjective but, for the doctor, highly significant symptom: an amelioration of the patient's peculiarly unpleasant general feeling. "I don't feel so queer now" is a stereotyped saying of such patients. When these signs appear, the dosage is suitable. Whenever we are able to determine quanti- tatively from the urine the insufficiency or any im- provement in the separation of the hormone, then we shall also be able to prescribe the dosage with mathe- matical precision. For the time being, it is important to note that even the present therapy is successful and represents one of the greatest achievements of medical research. I will not venture to say that the correction of the pathological process is effected by the hypophysis hot- mone alone. Moreover, we do not know how and in what manner it acts. It is possible that the mere pres- ence of the hormone is sufficient; perhaps it regulates the activity of the neighbouring large vegetative centres. In his excellent book, Raynaud speaks of "signes d'emprunt," i.e. of symptoms which are "bor- rowed" from the neighbouring vegetative centres, bu.t it may be possible that the vitamins also play some part in the process--a theory which I consider highly probable. References to a connection between the vitamines A, C, D and E and the hypophysis are ap- pearing with increasing frequency in medical litera- ture (Verz~r, Vogt, Moravitz, Abderhalden, Kiihnau). Possibly, the hormone stimulates some process which paves the way for the necessary vitamin or perhaps neutralizes the effect of an opposite vitamin. In the cogwheel-like arrangement of the endocrine system it may easily be that the failure of one factor impedes the other factors. However that may be, one thing is certain: that the anterior lobe hormone plays a domi- nant part in the treatment of Simmonds' disease, irres- pective of whether the action takes place directly or indirectly. Further research will throw light on the intricacies of the working mechanism. Value of a Routine Red Cell Sedimentation Test in Gastro-enterology By MEYER GOLOB, M.D. and HARRY BOROWSKY, M.D. NEW YORK, NEW YORK p ATIENTS attending a clinic for gastro-intestinal disorders usually complain of symptoms referable to the digestive system. Investigation however, often shows that the cause of the symptoms lies, not only outside the gastro-intestinal tract, but frequently out- side the abdomen altogether. Aware of this, the gastro-enterologist must not let himself be misled by the patient's concentration upon digestive manifesta- tions. He must rather, look beyond his own specialty, considering the patient as a human being--not as a mere digesting mechanism. Therefore, the red cell sedimentation test as applied in the broader field of general medicine, including ail- ments remote from the digestive tract, may very well become a valuable aid in gastro-enterological diagnosis. Even though a negative finding with the red cell sedi- mentation test does not positively exclude the existence of disease, the value of a positive sedimentation is in no wise lessened. When this is the only evidence of disease it may well excite the examiner to greater care, and has in many instances thus enabled wholly un- suspected pathological states to be made manifest. ~From the Gastro-iutestinal Department of the "New York Homeopathic Medical CoIIege and Flower Hospital. Submitted December 3, 1935. Thus its employment in a gastro-intestinal clinic, where cases of both types are continually encountered, will be as beneficial and helpful as this test has long since proved itself in clinics devoted to gynecology or the control of tuberculosis. Many authors have shown how closely related are the affections of the female genital tract and the gastro-intestinal system, while the relations which any type of tuberculous infection will establish with both these systems is too well understood to need more than passing mention. Runyeon (1) has illustrated this in the instance of the Krukenberg tumor, while Frieden- wald and Morrison (2) have made an elaborate analy- sis of the reciprocal relationship between gastro-in- testinal disturbances and pathologic conditions in the female pelvic zavity. It has been clearly demonstrated that such a test has practical clinical application in many conditions wherein it has not up to the present time, been used. THE TEST What we have here termed the red cell sedimentation test is known by a number of different designations. Since its introduction by Fahreus (3) in 1918 it has been called simply "the sedimentation reaction," or been known as

Value of a routine red cell sedimentation test in gastro-enterology

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GOLOB AND BOROWSKY--VALUE OF A ROUTINE RED CELL SEDIMENTATION TEST IN GASTRO-ENTEROLOGY 387

emphatically tha t these men are among the greatest benefactors of mankind.

As regards the dosage, no fixed rules can be laid down. I t is impossible to say whether 100 or 200-300 units a day will be required. I t depends entirely on the individual. I had patients who felt well when taking 100 units a day and others when taking 700 (seven hundred) units a day. The proper daily dose for the pat ient is that quanti ty of hormone on which he gains weight. I t varies greatly. Sometimes the increase in body weight begins late, but an improve- meat soon appears in the gastr ic symptoms, while the appetite and muscular s t rength increase; this improve- ment is accompan ied 'by a subjective but, for the doctor, highly significant symptom: an amelioration of the pat ient 's peculiarly unpleasant general feeling. "I don't feel so queer now" is a stereotyped saying of such patients. When these signs appear, the dosage is suitable. Whenever we are able to determine quanti- tatively f rom the urine the insufficiency or any im- provement in the separation of the hormone, then we shall also be able to prescribe the dosage with mathe- matical precision. For the time being, it is important to note tha t even the present therapy is successful and represents one of the greates t achievements of medical research.

I will not venture to say that the correction of the pathological process is effected by the hypophysis hot- mone alone. Moreover, we do not know how and in what manner it acts. I t is possible tha t the mere pres- ence of the hormone is sufficient; perhaps it regulates the activity of the neighbouring large vegetative centres. In his excellent book, Raynaud speaks of "signes d 'emprunt ," i.e. of symptoms which are "bor- rowed" f rom the neighbouring vegetative centres, bu.t it may be possible tha t the vi tamins also play some par t in the p rocess - -a theory which I consider highly probable. References to a connection between the vitamines A, C, D and E and the hypophysis are ap- pearing with increasing frequency in medical l i tera- ture (Verz~r, Vogt, Moravitz, Abderhalden, Kiihnau). Possibly, the hormone stimulates some process which paves the way for the necessary vi tamin or perhaps neutralizes the effect of an opposite vitamin. In the cogwheel-like a r rangement of the endocrine system it may easily be that the failure of one factor impedes the other factors. However that may be, one thing is certain: that the anter ior lobe hormone plays a domi- nant par t in the t rea tment of Simmonds' disease, irres- pective of whether the action takes place directly or indirectly. Fur the r research will throw light on the intricacies of the working mechanism.

Value of a Routine Red Cell Sedimentation Test in Gastro-enterology By

MEYER GOLOB, M.D. and

HARRY BOROWSKY, M.D. NEW YORK, NEW YORK

p ATIENTS at tending a clinic for gastro-intestinal disorders usually complain of symptoms referable

to the digestive system. Invest igat ion however, often shows tha t the cause of the symptoms lies, not only outside the gastro-intest inal tract, but frequently out- side the abdomen altogether. Aware of this, the gastro-enterologist must not let himself be misled by the pat ient 's concentration upon digestive manifesta- tions. He must rather, look beyond his own specialty, considering the patient as a human be ing- -no t as a mere digesting mechanism.

Therefore, the red cell sedimentation test as applied in the broader field of general medicine, including ail- ments remote f rom the digestive tract, may very well become a valuable aid in gastro-enterological diagnosis. Even though a negative finding with the red cell sedi- mentat ion test does not positively exclude the existence of disease, the value of a posi t ive sedimentation is in no wise lessened. When this is the only evidence of disease it may well excite the examiner to grea ter care, and has in many instances thus enabled wholly un- suspected pathological states to be made manifest .

~From the Gastro-iutestinal Department of the "New York Homeopathic Medical CoIIege and Flower Hospital.

Submitted December 3, 1935.

Thus its employment in a gastro-intestinal clinic, where cases of both types are continually encountered, will be as beneficial and helpful as this test has long since proved itself in clinics devoted to gynecology or the control of tuberculosis.

Many authors have shown how closely related are the affections of the female genital t rac t and the gastro-intestinal system, while the relations which any type of tuberculous infection will establish with both these systems is too well understood to need more than passing mention. Runyeon (1) has il lustrated this in the instance of the Krukenberg tumor, while Frieden- wald and Morrison (2) have made an elaborate analy- sis of the reciprocal relationship between gastro-in- testinal disturbances and pathologic conditions in the female pelvic zavity. I t has been clearly demonstrated that such a test has practical clinical application in many conditions wherein it has not up to the present time, been used.

THE TEST What we have here termed the red cell sedimentation

test is known by a number of different designations. Since its introduction by Fahreus (3) in 1918 it has been called simply "the sedimentation reaction," or been known as

388 AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

'the suspension stability reaction of the erythrocyto,' rapid cell sinking' or 'rapid cell settling,' or again as the 'ac- celeration of sedimentation velocity.' All these refer to precisely the same phenomenon, which may be briefly de- scribed as follows:

Sinking of the red blood corpuscles takes place in the presence of an anticoagulant, leaving a clear plasma. This sinking is more rapid when disease is present, than when the body is healthy. This test appears to be the acme of simplicity, but it must be emphasized that its proper in- terpretation is not the function of the laboratory techni- cian, but must be made by the clinician himself, as he alone is able to translate the findings in terms of all the other factors essential to recognition of disease in the body of the patient whose blood gave positive findings to the test.

The cell sedimentation rate is distinctly separate from the sedimentation time. For the time is inversely propor- tional to the severity of the disease; i.e. when the rate is increased, the time is lessened. The phenomena most significant for the test occur during the first hour. Beyond

tation rate always indicatc~ the pre~ence of disease of some kind; (2) but a normal rate does not exclude the presence of disease. (3) The rapidity of sedimentation is a measure of the severity of the disease, and when a level has been established in a given case, the rapidity of sedimentation provides a measure of the progress of the disease in that case.

That apprehension on the part of the patient may be a factor in erroneous readings of the test, is pointed out by Van Antwerp (7). To obviate this chance of error, he performs two sedimentation tests on succes- sive days upon all newly-admitted patients. The lower of the two readings is accepted as reflecting the pres- ence or absence of a destructive lesion.

VALUE OF THE TEST IN P E P T I C ULCER AND CANCER

A reliable means of differentiating between malig- nant and benign lesions of the digestive tract has long

Abstract of one hundred gastro-enterological cases and control s tudy of twenty- two normal senior medica~ students

Disease

Neuros is

Chronic gall bladder disease

Calcified ga l l b ladder

Duodenal ulcer I. W i t h o u t bleed- i ng or obs t ruc t ion

I L Bleeding, w i th and w i thou t ob- s t ruc t ion

Carc inoma of gas- tro-intestinal t r ac t

Ben ign achylia gas t r i ca

No. Cases M F

Low - - High M F

Average M F

5.05

25.5

6.8

23.2

24.8

3.5

17 9

2 9

I

6 2

7 2

4 3

2

2-18 4-13

~5-26 4-24

4

2-14 [4-14

[5-3~ [6.5-- L9.5

[5-3~ ~6-28

3-4 2 .5-- 7.5

8.07

19.8

4

14

18

26.3

5

Remarks

In these cases, no rma l sed imenta t ion rates, w i th nega- t ive physical f indings led to the d iagnosis of func- t iona l dis turbance.

Clinically, the ra te paral le ls the ac t iv i ty of the disease.

In th is s ing le case the low ra te showed the disease process to be inac t ive , i n d i c a t i n g an e n v i r o n m e n t un- fi t ted for microbic ac t iv i ty .

The test here gauges the ac t iv i ty of the lesion, wi th bleeding as the ma in feature. ]n one case, the ac t ive ulcer showed 37 ram., bu t only 7 ram. in the l a ten t period. Hemoglobin index rose as sed imen ta t ion rate fell. Lesions of the pos ter ior duodenal wall bled more, and there fore show a more rap id sed imen ta t ion rate than those on the an t e r io r w~ l .

In d i f fe ren t i a t ing between ben ign and m a l i g n a n t gas t r i c ulcer, i f a h igh sed imenta t ion ra te is obta ined in the presence of bleeding, i t is no t so ind ica t ive of mal ig - f a n c y as a h igh ra te when bleeding is not con- spicuous.

Rapid sed imenta t ion may occur independen t ly - -be fo re charac ter i s t ic symptoms appear . Rap id i t y of r a te appa ren t ly paral le ls advance of the disease process.

In t rue acbylia gas t r i ca the sed imenta t ion tes t differen- t i : tes between ben ign and m a l i g n a n t types, a h igh rate usual ly i nd i ca t ing mal ignancy .

that period very little information of value can be ob- tained. Of the many hypotheses advanced to account for t.hese phenomena, that most generally accepted is that in the presence of disease there is increased tissue destruc- tion and the liberation of fibrinogen in the blood stream, with ensuing clumping of the cells. The larger the clumps, the more quickly will they sink.

I N T E R P R E T A T I O N OF THE TEST Charting the sedimentation values in different types

of cases, Cutler (4) obtained four graphs which he names horizontal line, diagonal line, diagonal curve, and vertical line. "Of these," he writes, "the hori- zontal line alone is normal. The other three graphs are always abnormal findings and always indicate dif- ferent degrees of the intensity of the destructive process." "Its chief value," remarks Haskins (5), "is not in differential diagnosis but in following the course of the individual case, and in giving a clue to unsus- pected infection, inflammation or malignancy in per- sons in whom a normal rate has been expected." In much the same strain Bannick (6) calls attention to three general principles: (1) An increased sedimen-

been sought by gastro-enterologists without avail. Does the red cell sedimentation test fill this need? Rubin (8) avers that in its early stages cancer does not necessarily induce an increased sedimentation rate, and cites a case of carcinoma of the esophagus, where- in the patient, otherwise in good physical condition, had a normal rate. Eleven months after the test was made the patient was returned to the hospital, and died shortly after of cancer, thus demonstrating that the sedimentation test may be unreliable when malig- nancy is in a very early stage.

As regards peptic ulcer, or its differentation from gastric cancer, Rubin, writ ing in collaboration with Morriss (9), and later (10), makes several citations from literature tending to indicate that the sedimen- tation test is of diagnostic aid when ulcer must be differentiated from cancer of the stomach, as cell settling has been shown to occur more rapidly if the lesion is malignant. Our own findings, in a compara- tively small series of cases, tends to confirm the views which Rubin quotes. We agree with Held and Gold- bloom (11) who found that though the sedimentation

GOLOB A N D B O R O W S K Y - - V A L U E OF A R O U T I N E R E D C E L L S E D I M E N T A T I O N T E S T I N G A S T R O - E N T E R O L O G Y 389

Miscellaneous Cases. Too Few to Pe~nnit Conclusions to be Drawn From Them. (Rapid red cell sedimentation fixes attention, leading to further observation and repeated testing to reveal the lesion; normal rate of sedi- mentation, correlated with other negative factors, justifies the assumption theft disease is not present)

Disease

Acute retrocecal appendicitis

Acute suppurat ive appendicitis

Va~ue gast r ic dis turbances; met ror rhag ia

De-~tal seps is : gastr ic disturbance

Irr i table colon

Lamblia duodenitiq

Glenard's disease

Gastric hyperacidity

Deferred diagnosis

Gastric hyperacidity

Umbiqcal he rn ia : hyperchlor- hydria

Tuberculous pleurisy

Neuresyphi!i~

Syphilis

Amebic ulcerative c~litis

Non-specific ulcerative c,~l'ti~

Periodic health examinatio,~

Neurogenic diarrhea

Diverticulosis ; diverticulitis

Gastro-enterogenous diarrhea : cholecystectomy : infection

Acne and vague gastr ic disturb- ances

Graves ' disease

Nutri t ional ar, emia

Ery thremia (persis tent polycy- themia or Vaquez's disease)

Migraine of biliary (? ) origin

Cardiospasm

Non-infectious granuloma abdom- inis

Diabetes mellitis

Major epilepsy

Ulcer at pyloric end of stomach

Pregnancy

Roentgenologically diagnosed ap- pendicitis

Pyorrhea alveolaris; reversed per- igtalsis (Alvarez syndrome)

Anxiety reuros i s ; ( fear of ap- pendicitis)

~0

!3

7

ll

,)3

;-15

L-16

~-25

L-16

L5

23

12

30

23

15

4

27

17

3-16

7

15

0

21

15

2-14

19

4

12

19

3

7

11

Remarks

This case presented the classic symptoms of cholelithiasis; the white count showed a polymorphonuclear leukocytosis, with a marked shif t to the left. Gall bladder normal cholocystographiely.

Clinically unusually quiescent, operation in this case revealed appendieeal suppuration.

Nullipara, 40, no misca r r i ages ; husband's blood Wasse rmann repeatedly nega t ive ; own Wassermann, 4-plus. Vague symptoms of indigest ion; diplopia following influenza; no clinical lesion demonstrable. Pat ients with positive Wassermanns but showing a normal sedimentation, appear to have latent syphilis. The test, therefore, differen- tiates between latent and clinically active syphilis.

Control Tests On tIealthy Individuals The normal controls were recruited f rom the senior class (1935) of the Homeopathic

Medical College and Plower Hospital consist ing of 22 male students. Only apparent ly healthy individuals, free f rom cold or any infectious conditions were asked to submit themselves to the test.

The following results were obtained: Highest sedimentation rate 11 ram. Lowest sedimentation rate 1 ram. Average 4.3 ram.

All these readings are well within normal limits, and go to show, despite the very small numbers tested, that in individuals proved healthy a f te r adequate physical examina- tion, the sedimentation phenomenon will present a picture in no wise va ry ing beyond normal limits.

rate was not increased in benign ulcer, when carcino- matous degeneration took place in such an ulcer, the rate was increased very regularly. All of our own cancer cases have shown a rapid erythrocyte sinking. We are therefore, of the opinion, that the red cell sedi- mentation test has distinct diagnostic value when striving to differentiate between ulcer and cancer of the gastro-intestinal tract. The findings of such authors as Barthold (12), who claims that the test is

valueless in either extreme of the malady--the very early case or that which has advanced to the stage of cachexia--do not, in our opinion, find any application in the general run of cases seen in routine gastroo enterological practice. The results of investigations made by Lorie (13) several years ago, bear out our views. We would suggest that a gastric ulcer, in the presence of a low rate of settling, may be regarded as benign, if there is no associated gastris or duodenitis.

390 AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

Relation of the Test to Hemoglobin Readings: The relation of hemoglobin to the red cell sedimentation findings was studied by Rubin and Smith (14) almost a decade ago. Most of their findings have been paral- leled by our own experience. We found, for example, that a high hemoglobin count accompanied augmented sedimentation. Any diagnostician will agree that a high hemoglobin count, considered by itself merely serves to increase confusion, but if we can interpret it in terms of rapid cell sinking, it becomes at once a valuable diagnostic factor. The statement that "the hemoglobin content of the red blood cells parallels to a certain degree, the erythrocyte sedimentation reac- tion," was substantiated by our own experience. We have not kept a complete account of the relationship of the red cell count to the sedimentation results, but the few records regularly reveal a very close alliance--a low hemoglobin index implied augmentation in red cell sinking.

Achylia Gastrica: Though the differentiation be- tween benign and malignant achylia is quite well standardized, the red cell sedimentation test should be of service in the diagnosis of this condition. The sedi- mentation rate has been shown to be unaltered in benign achylia, but increased in the malignant forms. True achlorhydria may be benign in a benign gastric tumor, when the sedimentation rate will be normal. But should the nature of the growth change, as in that mentioned by Sanders (15), demonstrated by Rubin at Montifiore Hospital, when the tumor develops central necrosis, or becomes infected, a rapid sinking of the red blood cells will be immediately perceptible. And the rapidity of this sinking will furnish an index of the extent and severity of malignant tissue destruc- tion. The achylia of syphilis or pernicious anemia, or that frequently associated with a tuberculous infection, if estimated by the red cell sedimentation test, must be interpreted in terms of these respective maladies.

Bleeding and Nor~-Bleeding Peptic Ulcer: The anemia resulting from a bleeding gastro-duodenal ulcer alters the normal sedimentation rate. When bleeding ceases, the rate of red cell settling approaches normal, and thus points to a propitious time for s~r- gery, if the case be one where surgery is otherwise indicated. This analogy holds good for mucus colitis, as well as cholelithiasis, both uncomplicated, or with attending inflammation.

The cases included in the first part of our Table pre- sented generally similar characteristics: Hyperchlor- hydria, a hemoglobin index ranging from 36 to 54 per cent, a red cell count of from 2.5 million to 3 million, and a sedimentation rate between 22 ram. and 38 mm. in 60 minutes. The duodenal cases showed the classic syndrome of a post-pyloric lesion, marked hyperchlor- hydria with persistent deformity of the bulb, though the lesion did not cause obstruction and did not bleed; a hemoglobin index of 95 per cent, and a red cell count of five million. The sedimentation rate was regularly a horizontal line--2.2 ram. in 60 minutes. The value of the red cell sedimentation test in such instances is certainly obvious.

In the tedious period of convalescence which marks these ulcer cases, the test serves as a continual guide and check upon treatment. Should erosion of a blood vessel bring about sudden hemorrhage, the extent and activity of the bleeding, with the degree of tissue de- struction involved will be registered in the behavior of

the erythrocytes every time the test is applied. After surgical intervention, an increased sedimentation rate indicates the amount of traumatic tissue damage and the different phases of the absorption process. A per- sistently high sedimentation rate gives strong evidence of the existence of a complication. Yet the test must not be regarded as a substitute for blood cytology. Indeed, it is not a substitute for anything. I t is an addition to all the previously employed methods. I t even has psychic aspects. Gallagher (16) has employed it to detect evidences of chronic disease in subjects whose past history suggests the possibility of its ex- istence. He avers that "The finding of a normal sedi- mentation rate has given us greater confidence in the advisability of expectant treatment, and in our at- tempts to reassure the patient."

Anemia Due to Colon Malignancy: Differentiating the various degrees of anemia due to bleeding of malignant lesions in the colon, necessitates taking into consideration the precise location of such lesions. As Heald (17) has put it, "The blood picture differs with the location of the lesion. It is a well established fact that secondary anemia is more marked with r ight side tumors than with left." The right half of the colon is of greater calibre, permitting larger growths to de- velop with more bleeding surface, and a resultant higher grade anemia. In the r ight half moreover, adenocarcinoma is the prevailing type of neoplasm, in contrast to the annular, constricting type likely to be found in the left half of the colon. Since the rate of red cell sedimentation varies with the degree of anemia, a higher rate would, therefore, point to a malignant lesion in the right colon. A large bleeding surface in the right colon may induce a blood picture readily mistaken for that of pernicious anemia. In this type of case every "lead" is of value, and the ap- plication of the sedimentation test may give invaluable evidence as to the location and extent of the lesion, and the severity of the tissue destruct ion--perhaps even resulting in a saving of priceless time sufficient to evert a fatal termination of the disease.

To the gastro-enterologist, as to medical practition- ers in all divisions of the science, the red cell sedimen- tation test should prove an invaluable aid. While alone and unsubstantiated, it will not serve for differential diagnosis, or even demonstrate the presence of any given disease, nevertheless it serves to warn the clini- cian that disease of some kind is present. As the speed with which the red corpuscles sink is in direct proportion to the intensity of this disease process-- though we must allow for the factor of anemia--a postive finding is a most valuable aid in diagnosis, even if a negative result does not necessarily indicate that no disease is present.

CONCLUSIONS

1. The red cell sedimentation test merits a place in the diagnostic equipment of the gastro-enterologist, as an aid in the diagnosis of diseases in which infec- tion or tissue destruction are important factors.

2. Where no direct external evidence of disease exists, but the test shows a departure from normal conditions, the examiner will be stimulated to fur ther scrutiny of the available evidence. This is of par- ticular importance where a neurasthenic state, or frank neurosis is present, as under these conditions a normal sedimentation rate will assure the examiner

TwIss A N D H A N S S E N - - B A C T E R I O L O G I C A L F I N D I N G S I N D I S E A S E OF T H E B I L I A R Y T R A C T 391

that he is not overlooking a physical ailment which is masked by the psychic state.

3. The test does not supplant any diagnostic meas- ure now employed, but provides additional confirma- tion of their findings.

4. Though the present study is admittedly limited in respect to the number of cases, it offers convincing evidence as to the value of the test in determining the activity or latency of a malady, giving information as to tissue breakdown such as occurs in malignancy, or if inefficiency of the blood-forming mechanism, as in anemia due to excessive hemorrhage.

5. Since many wholly unrelated pathologic condi- tions produce symptoms apparently referable to the gastro-intestinal tract, the routine application of this test should operate to separate those cases within the gastro-enterologist 's province from those which properly belong to other specialists. To illustrate: If the gastro-intestinal examination showed no lesion in the canal, a normal stomach chemistry, and an X-ray film without filling defects or other evidence of path- ologic distortion, then an accelerated sedimentation

rate should at once stimulate a search for a disease condition unrelated to the digestive canal.

6. The red cell sedimentation test resembles the leucocyte count in that it is not specific for any disease even when positive, and if negative does not neces- sarily indicate that n o disease condition is present.

7. In the presence of a known pathological condi- tion normal sedimentation indicates that the disease process is inactive; a speedy sinking of the red cor- puscles indicates that the converse is true. The test can, therefore, be utilized as an aid in prognosis.

8. The present study is based on 100 consecutive clinic cases wherein the sedimentation test was em- ployed, and upon the results obtained by applying the test to 22 normal individuals who volunteered to act as controls.

The writers wish to express their appreciation of the help and interest of Dr. Addle Stanford in the work here recorded, as well as to the members of the graduating class of 1935, without whose assistance it could not have been brought to an adequate conclusion.

R E F E R E N C E S 1. Runyeon, F. G.: The Krukenberg tumor. J . A. M. A., ciii: l199,

Oct. 20, 1934. 2. Friedenwald, Julian, and Morrison, S . : Some observations upon

the reciprocal relationship between gastro-in&estinal and female pelvic disturbances. Am. J. Digest. Dis. c~d Nutr~t., i:609, Nov., 1934.

3. Fahraeus, B. : Ueber die Ursachen der verminder ten Suspensions- stabitit i i t der BlutkSrperchen whrend der Schwangerschaft .

" Bichem. Ztschr., lxxxix:355, 1918. 4. Cutler, J . W. : The practical application of the blood sedimenta-

tion test in general medicine; observations based upon approxi- mately 5,090 pat ients over a period of 6 years. Am. J . Med. Sc., clxxxiii :643. May, 1932.

5. Haskins, H. D., vt al: A rapid method for the determination of the sedimentation rate of the red blood cells with results in health and disease. J. Lab. and Clin. Med., xvi :No . 5, 487, Feb., 1931.

6. Bannick, E. G.: Sedimentation ra te of the blood; its practical application in clinical medicine; pre l iminary report. Proc. Staff Mtgs. Mayo Clinic, viii:81, Feb., 1933.

7. Van Antwerp, L. D. : Repeated sedimentation tests. Am. J. Dis. Child., xlviii:814, Oct., 1934.

8. Rubin, E. H . : The sedimentation reaction in cancer. Am. J. Med. Sc., cixxiv :680, Nov., 1927.

9. Rubin, E. H., and Morriss, W. H . : The sedimentation reaction

of erythrocytes; clinical applieatio~mS and micromethod. J. Lab. and Clin. Med., xi:1045, Aug., 1926.

10. Rubin, E. H. : The clinical value of the erythrocyte sedimentation reaction in surgery. S. G. O., xlii:652, May, 1926.

11. Held, I. W., and Goldbloom, A. A. : Carcinomatous degeneration of peptic ulcer. Surg. Cl~. North America, xiii:l~o. 2, 387, April, 1933.

12. Bertho]d, E . : ( Invest igat ion regarding the changes in the veloicty of the sedimentation of blood corpuscIes in cases of mal ignan t tumors ) . Untersuchung ueber die Veranderungen der Bliitkor- perchen-Senkungsgeschwlndigkei t bet bSsartigen Geschwiilsten. Monatschr. f. Krebska~npf., i:449, Dec., 1933.

13. Lorie, I w a n : Die erythrozyten-Senkungsreaktion bei Magenkrank- heiten. Archiv. f. Verdaus.-Krankh., 1ii:171, Sept.. 1932.

14. Rubin, E. H., and Smith, N. : Relation of hemoglobin, cell count and cell volume to the erythrocyte sedimentation reaction. Arch. Int . Med., xxxix:303, Feb., 1927.

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Bacteriological Findings in Disease of the Biliary Tract The Relationship of Gastric Acidity to Biliary Tract Infection

By

JOHN RUSSELL TWISS, M.D.

and

EILIF C. HANSSEN, M.D. NEW YORK, NEW YORK

T HE determination of infection of the biliary tract has presented such a variety of technical difficul-

ties that there are no published reports in which the diagnostic value of biliary tract drainage has been entirely confirmed. A fur ther complication of this situation is that there is little information available as to biliary tract infection and its relationship to gastric acidity. Whipple (1) in a series of 25 patients

'~From the Depar tments of Surgery and Medicine of the New York Post Graduate Hospital.

This work has been aided by a g r a n t f rom the Oliver Rea Fund. Submitted April 22, 1936.

going to operation reported that organisms similar to those found in cultures of the biliary tract were ob- tained in the pre-operative duodenal drainage bile in 54%. This percentage of accuracy in diagnoses sug- gests that the duodenal drainage findings represent a casual rather than a diagnostic relationship to the actual conditions of infection in the biliary tract. Lyon (2) in another series reported a majori ty of cases showed similar findings, no definite figure being available. Among others Boardman (3) and Nauss, Lake and Torrey (4) have questioned the value of