SUBACUTE BACTERIAL ENDOCARDITIS

tonsillitis, active syphilis, all acute infections, suppurative processes, thyreotoxicosis, burns and wounds, various tropical diseases, nephritis and malignant disaase. Despite this, the test is a valuable one. Its chief virtue is its sensitivity, for there is general agreement that it Indicates activity of a disease process when other signs, such. as fever and leucocytosis, have ceased to be of value. Its greatest use, therefore, is in following the progress of chronic diseases, partteularly rheumatism and tuberculosis, in which the physician's most powerful therapeutic weapon is bid rest while the disease remains active. It is worth noting that active tuberculosis or rheumatism occasionally fails to alter the suspension stability of the red cells. In simple chorea, indeed, this is the usual finding. The test may be of diagnostic value in distinguishing functional from organic disease, as Massell suggests; but it must be remembered that an accelerated rate may be caused by a relatively symptomless organic process that is quite apart from the suspected functional one. It has been suggested too that the estimation of corpuscular stability should be part of the routine examination of a supposedly healthy person. The finding of an accelerated rate would be an indication for a diligent search for organic disease. S. W. Cutler is reported by Massell to have used the test in this way, and to have discovered cases of latent tuberculosis, syphilis, pelvic inflammation and one case of carcinoma of the lung. There remains the question of technique, and here the confusion is perhaps greatest. Some of the various methods are designed for research, some for routine use. Some measure the rate of fall over short intervals, some the time taken for the cells to fall a certain distance, some the distance fallen in a longer period, like one and two hours. The anticoagulant, the bore of the tube and the correction for the hrematocrit reading and room temperature vary from method to method. To make confusion worse, many laboratories adopt modifications of the standard methods to suit their own convenience. The consequence is that accurate comparison between results obtained by various workers is well nigh impossible. It would be well if an organized attempt were made to standardize both the application and the technique of the test. The test, of course, will probably always remain subordinate to clinical methods because of its non-specific nature, and some physicians will find more use for it than others. But an attempt should be made to unify and simplify technique, so that each clinician will be able to understand what the other means by his results.