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THE PERIODIC INVESTIGATION OF THE ERYTHROCYTE
SEDIMENTATION RATE IN RHEUMATIC CHILDREN.
By R. S. C. McDade, M.A., M.B., B.Ch., Assistant Medical Officer, High Wood Hospital.
The decision as to whether or not a case of rheumatism in a child is active, is
in many instances a matter of very considerable difficulty ; and it has been felt
that some reliable routine test which would supplement the clinical findings in such
cases would be of real value in the treatment of the disease.
During the last few years several writers—Bach and N. Gray Hill1,3, W. W.
Payne2, C. Bruce Perry4 and others—have shown how closely the erythrocyte
sedimentation rate parallels the clinical course of rheumatic carditis, and have indicated
the value which this test may prove to have in the estimation of the activity of
such cases.
During the last eight months at High Wood hospital, erythrocyte sedimentation
rate estimations have been performed each month on every case of rheumatism,
with a view to assessing the value of the test as a routine measure in the treatment
of cases of this kind.
The method employed has been the Westergren method, and any reading
higher than 10 on the Westergren scale has been considered abnormal. Each
reading is taken once only, at the end of one hour.
The test has been carried out on 246 cases, and in each case several monthly
readings have been obtained and charted. Some of these were cases which had
been in hospital some little time before the routine sedimentation tests were introduced,
and in which activity had appeared to have ceased. Others were admitted
after the introduction of the tests, and a series of monthly readings is being obtained
throughout the whole length of their stay in hospital.
It has, moreover, been the custom to carry out the erythrocyte sedimentation
rate test on the day preceding the ordinary routine examination of the patient, and
it has, therefore, been possible to obtain an outline of the clinical picture at the
•time each test was performed.
Out of the 246 cases on which the test has been periodically carried out, 85
showed at some time during the last eight months clinical evidence of activity.
Out of these 85 cases 76 (i.e. 89 per cent.) showed E.S.R. readings which were above
10 over a definite period. The remaining 9 cases (i.e. 11 per cent.) showed no rise
in the E.S.R. reading.
The nature of these 9 cases was as follows:—
In seven cases active chorea was present, but no other rheumatic manifestation.
In one case rheumatic carditis was present, but in this case, although some clinical
evidence of activity appeared to be present, there was considerable doubt as to
whether the disease really was active.
The ninth case was one of carditis, in which activity had apparently ceased
before the periodic E.S.R. tests were commenced, and a series of normal E.S.R.
readings was obtained. The patient then had a very severe relapse during which
the signs of congestive oedema rapidly appeared and the patient died. The E.S.R.
did not in this case rise above 10 after the relapse had taken place, when the carditis
was undoubtedly active. The E.S.R. test, however, was not carried out during
the short interval between the onset of the relapse and the appearance of the congestive
oedema; and this may be a possible explanation of the failure of the E.S.R.
to rise. C. Bruce Perry4 has described two cases of congestive oedema, occurring in
cases of active rheumatic carditis, in which the E.S.R., which during the period of
activity had been raised, fell below 10 when the oedema appeared. In one of these
cases the patient recovered, and the E.S.R. rose again with the disappearance of the
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