T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Vol. 36, No. 6, pp. 537-538
December, 1961
Copyright © 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
LETTER TO T H E EDITOR
T H E L E E AND WHITE T E S T FOR COAGULATION TIME
In their article entitled "Coagulation
Times of Blood Collected from Cutaneous
Punctures, as Determined in Plastic Capillary Tubing" (the JOURNAL, 35: 284-287,
1961), Atkinson and his associates make
several statements that should be amplified.
The authors seem to be aware of the faults
and deficiencies of the Lee and White test
for coagulation time. Their statement, however, that milder defects in the hemophilia
group will be missed occasionally by this procedure, may mislead some of your readers.
Diamond and Porter 3 observed that, of all of
their patients with hemophilia, as many as
20 per cent had normal Lee and White
clotting times. Inasmuch as their series included many severe instances, this percentage is considerably higher when only mild
cases are considered, and it is the patients in
this group who are likely to represent diagnostic problems. Thomas and associates10
report that the Lee and White clotting time
was normal in 4 out of 24 instances in a series
of patients with hemophilia, and in 1 out of
3 cases of patients with plasma thromboplastin component (PTC) deficiency; the 5
patients with normal clotting times were all
mild cases. Biggs and Macfarlane,1 in a
series of 20 cases of Christmas disease, observed that only 7 of the patients had prolonged Lee and White clotting times, and
these were the most severe examples. In 138
patients with hemophilia (antihemolytic
globulin (AHF) deficiency), these workers
observed that all of the mildly affected patients had short clotting times, although
some of these patients with normal clotting
times had severe disability. Pitney 7 observed
that all 19 of his patients with mild hemophilia had normal clotting times. It is clear,
therefore, that if the Lee and White test for
clotting time is used, the great majority of
instances of mild hemophilia will not be
recognized. In the more severe instances, the
diagnosis is usually obvious, on the basis of
the clinical history and clinical findings. The
only diagnostic problem in such patients is
to determine the type of hemophilia. For
this reason, Diamond and Porter 3 and
Fletcher4 have pointed out that the Lee and
White test for clotting time is a useless, if not
a dangerous, screening test. Quick8 has commented that at a former conference he made
the remark that, as far as he was concerned,
he would "throw the clotting time test out
of the window." He thought that he had so
disturbed the audience that they were going
to throw him out of the window. Inasmuch
as Atkinson and his associates state that
their new method is as reliable as the LeeWhite venipuncture method, and results in
similar information, it seems that this new
test, also, is of no value as a routine laboratory screening test.
The authors state that it is well known
that glass capillary methods can not be used
for the management of patients who are
under the effects of anticoagulant therapy
with heparin. After experience with the Lee
and White, and with the capillary methods,
I prefer the latter. I use the capillary tube
method of Dale and Laidlaw2 for the control
of patients who are being treated with
heparin. In accordance with this method,
blood is drawn into a short capillary tube*
that is slightly constricted at each end and
contains a lead bead. The method has many
advantages over the Lee and White method,
which I have discarded completely. The
capillary method can be completed in a considerably shorter period of time than the Lee
and White method. The normal is almost
invariably less than 2 min.,6 and, when prolonged by heparin, rarely exceeds 15 min.
The Lee and White method ranges from 4 to
12 min., and, after heparin, may be as long
as 1 hr. Patients being treated with heparin
bleed easily, and a free flow of blood can
readily be obtained by means of ear-punc-
537
* These can be made readily, or, on the other
hand, may be purchased from R. B . Turner and
Company, 9-11 Eagle Street, Southampton Row,
London, England.
538
Vol. 36
L E T T E R TO T H E E D I T O R
ture. Thus, contamination with tissue extracts is minimal, but, even in the presence
of tissue extracts, the clotting time in such
persons is still prolonged; venous blood may,
of course, be used instead of capillary blood
if the patient has an indwelling venous
catheter. I wish to re-emphasize that this
test should be used only for the control of
patients being treated with heparin. For routine screening work, I use the partial thromboplastin time of Langdell,6, 9 the one-stage
prothrombin time, and bleeding time tests;
but, as Diamond and Porter 3 emphasize, a
carefully composed family history and past
history, and an adequate physical examination, as well as the examination of a smear
of peripheral blood, are more informative
and effective screening procedures.
CECIL HOUGIE, M.D.
Hematology Director
Clinical Laboratories
University Hospital
University of Washington
Seattle 5, Washington
of 187 cases.
1958.
2. D A L E , H . H . , AND LAIDLAW, P . P . : A simple
coagulometer.
362, 1911.
1. B I G G S , R.,
AND M A C F A R L A N E , R.
G.:
Hae-
mophilia and related conditions: a survey
J . P a t h . & Bact., 16: 3 5 1 -
3. D I A M O N D , L. K.,
AND P O R T E R , F . S.:
The
inadequacies of routine bleeding and clotting
times. N e w England J . Med., 259: 10251027, 1958.
4. FLETCHER, R . : The routine bleeding and clotting time t e s t s : their medicolegal s t a t u s .
Laryngoscope, 68: 1087-1094, 1958.
5. L A N G D E L L ,
R.
D.,
WAGNER,
R.
H.,
AND
B R I N K H O U S , K . M . : Effect of antihemophilic
factor on one-stage clotting t e s t s . A presumptive test for hemophilia a n d a simple
one-stage antihemophilic
factor
assay
procedure. J . L a b . & Clin. Med., 4 1 :
637-647, 1953.
6. M O R R I S , I . B . : Normal clotting time. B r i t .
M. J . , 1: 248, 1951.
7. P I T N E Y , W. R . : Mild haemophilia—a clinical
and laboratory study. Australasian A n n .
Med., 6: 44-52, 1957.
8. QUICK, A. J . : N e w blood clotting factors.
T h r o m b . D i a t h . Haemorrh., 3 : 158, 1959.
9. RODMAN, N . F . , J R . , B A R R O W , E . M . , AND
GRAHAM, J . B . : Diagnosis and control of
the hemophilioid states with t h e partial
thromboplastin time ( P T T ) test. Am. J .
Clin. P a t h . , 29: 525-538, 1958.
10. T H O M A S ,
REFERENCES
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