Hospital morbidity and mortality of infantile eczema

EPSTEIN: 21. 22. 23. 24. 25. 26. 27. 28.

HOSPITAL MORBIDITY AND MORTALITY OF ECZEMA

541

Pohle, F. J., a~d Stewart, J. ]~i.: J. Clin. Investigation 20: 241, 1941. Clay, tI. L:, and Moore, J. W.: Clinics 1: 980, 1942. Lippman, 1~. W., and Bakst, H.: J. Lab. & Clin. ivied. 27: 777, 1942. Yardumian, E:. Y., and WMsband, B. J . : Am. J. Clin. Path. 13: 383, 1943. Nadler, S. B., and Butler, M. F.: Surgery 11: 732, 1942. Lawson, E. H., and Engelhardt, K. T.: New Orleans M. & S. J. 95: 60, ]942. Kirschnor, P. A., and Glickman, S. I.: J. Lab. & Clin. Med. 28: 1721, 1943. tIeifetz, C. J., Probstein, J. G., and Gray, S. I-I.: Arch. Int. Med. 67: 819, 1941.

H O S P I T A L M O R B I D I T Y AND M O R T A L I T Y OF I N F A N T I L E E C Z E M A A REPORT OF ONE IIUNDRED CONSECUTIVE HOSPITALIZED CASES OF INFANTILE ECZEMA

WITHOUT DEATHS

STEPHAN EPSTEIN, M . D . MARSHFIELD, WIS. W I T H THE ASSISTANCE OF SISTER M. LUITGARDIS, RECORD LIBRARIAN

T

I I E occurrence of severe complications and even death among infants hospitalized because of infantile eczema has led to repeated warnings that children with eczema should not be admitted to a hospital, but should be taken care of at home or at a foster home. However, this is not always possible or practical, especially in severe generalized eczema. Such cases are quite common in rural districts; they are frequently due to sensitivities to environmental factors such as cattle dander. In these instances management at home is very difficult or even impossible.

F r o m Jan. 1, 1937, to J u n e 30, 1944, one h u n d r e d cases of infantile eczema were hospitalized at St. Joseph's Hospital, Marshfield, Wis. No deaths occurred among these children. The following is a report of this series with a discussion of causes of hospital morbidity and mortality of infantile eczema. PRESENTATION

OF CASES

This report covers all infants with eczema up to 2 years of age. The term eczema is used here in the broader sense as it is commonly applied. 22 Eczema in infants can rather readily be grouped clinically in four groups:

I. Atopic dermatitis.--Atopic dermatitis is the most common form of eczema in children. It begdns early in life, frequently between the second and fourth nlonth. It is characterized by a more or less acute, itching dermatitis. Practically always the face is involved bdt frequently it extends to arms, legs, and body. The child may be covered with scratch marks. Other manifestations of atopy may be present. 2. S~borrheic Dermatitis.--Seborrheic dermatitis often appears during the first few weeks of life with the well-known scaly eruption of the scalp commonly called " c r a d l e c a p . " Later lesions appear on the face and body. Typical cases are characterized by sharply outlined, erythematous, scaly lesions, without pruritus. Combinations of atopic and seborrheie dermatitis are not infrequent. 3. Contact Dermatitis (Epidermitis).--In infants contact dermatitis is usually manifested by an acute or subacute dermatitis of relatively short duration. As a rule, it is not symmetrical and relatively rarely involves the face. :From St. Joseph's Hospital and the Marshfleld Clinic.

542

THE

JOURNAL

OF P E D I A T R I C S

I t is most' common on the legs and buttocks but may affect any p a r t of the body. In this group are included those cases of dermatitis that clinically resemble epidermitis without definite proof that they are contact dermatitis. 4. Infectious Eczema (Chiefly That Form Called Intertrigo).--Intertrigo is manifested by eroded, usually more or less sharply outlined patches of eczema in the folds along the neck, axillae, and groins. It is a p p a r e n t l y a form of infectious eczema, p a r t l y of bacterial origin (streptococcus or other bacteria), p a r t l y of fungus nature (monilia or other yeastlike fungi). Heat and moisture and the ensuing maceration are important contributing factors. In order to permit comparison with previous reports the eczema eases are here presented in table form similar to those of Koch and Schwartz, 1 Glaser and Edwards, 2 and Sehwartzman and associates, a E v e r y admission was counted as a new ease. There was a total of one hundred admissions, fifty-eight male and forty-two female. Two infants were admitted twice; and one, three times. Tables I and I I present the eczema eases grouped according to the classification we have presented. The eases of atopic dermatitis (1 to 78) are reported separately in Table I. e. All other eczemas (79 to 100) are given in Table II. Table I I I presents a control group. INCIDENCE OF MORBIDITY (COMPLICATIONS)

A total of twenty-three complications (in twenty-one infants) was recorded, making the incidence for the whole series of one hundred cases twenty-three per cent. Of the siXty-four infants adniitted with uncomplicated eczema, fifteen (23.4 per cent) developed complications. Of the thirty-six infants who presented complications on admission, six (16.6 per cent) acquired additional complications. The difference of the rate of complications between these two groups is of no significance. There is, however, an important difference between the atopic and nonatopic children. Table I V shows that all complications but one occurred among the infants with atopic dermatitis. N A T U R E OF C O M P L I C A T I O N S

Table V lists the nature of complications developed by the children with infantile eczema. The complications contracted at the hospital were nearly all infections of the respiratory or gastrointestinal tract. The situation in regard to complications present upon admission is entirely different i(Table V I ) . Table V I shows that skin infections were common in both the atopic and nonatopic groups. But of the respiratory and gastrointestinal complications again all but one were observed among the atopic children. There was nothing particular about the various complications from which the infants with eczema

suffered except three instances of that peculiar smallpoxlike eruption which is now generally called Kaposi's varieelliform eruption. This is quite an alarming complication and deserves more attention than it has had. The three cases, therefore, shall be briefly reported. The disease has been discussed recently by several authors (Barton and Brunstingr Lynch, ~ Wenner6). *Table I shows that atopie dermatitis, either alone or combined with seborrheie dermat i t i s , a c c o u n t s f o r m o r e t h a n t h r e e - q u a r t e r s o f all t h e e e z e m a s i n t h i s s e r i e s . In general, a t o p i e d e r m a t i t i s is t h e m o s t c o m m o n f o r m o f i n f a n t i l e e c z e m a . It would appear even more s o i n a g r o u p Of h o s p i t a l i z e d b a b i e s , b e c a u s e t h e o t h e r f o r m s of e e z e m s , i e s s f r e q u e n t l y r e q u i r e hospitalization.

EPSTEIN:

Kaposi's

HOSPITAL

varicelliform

eruption

v a c e i n i a a n d is c h a r a c t e r i z e d On top of a pre-existing also of adults,

M O R B I D I T Y A N D M O R T A L I T Y OF E C Z E M A

is s i m i l a r

dermatitis,

a vaccinia

in some respects

by a constitutional usually

like eruption

rather

Eczema

eczema

been vaccinated Kaposi's

However,

the

I

or confluent.

latter

themselves

or have

eruption, as

come in contact

condition.

who either have

with vaccinated

recent investigations

The

This condition

is a d i f f e r e n t

is g e n e r a l i z e d v a e c i n i a i n e c z e m a p a t i e n t s

varieelliform

but

The patient

Clinically we find the typical

l e s i o n s of v a c c i n i a , e i t h e r s i n g u l a r

vaecinatum.

vaccinatum

or

severity.

of i n f a n t s ,

rapidly.

whole face may be involved and turn into a swollen, eroded mass: resembles

to variola

ol unusual

atopic dermatitis

appears

shows signs of a severe infection with high fever. depressed vesiculopapular

reaction

543

persons.

have demonstrated,

is

a s e v e r e i n f e c t i o n d u e t o t h e v i r u s o f h e r p e s s i m p l e x . 4, 5, 6 I n m y t h r e e cases, K a p o s i ' s

eruption was superimposed

on atopic dermatitis.

CASE 1 (Table I, Case 2 0 ) . - - & G., 16 months of age, was admitted March 11, 1941. Eczema of face and arms had been present for the past fourteen months. One week prior to admission, the mother had noticed a papular eruption on the face which turned into pustules two days l a t e r . A t the same time fever was noticed. The chil,d appeared ill. Two days after the onset, the patient appeared rather stuporous. The lesions on the face became worse and new lesions appeared on the face and wrists. Neither the child nor anyone in the family had been recently vaccinated. Upon admission the child presented the typical picture of a weeping infantile eczema covered with numerous, smallpoxlike pustules. There was marked enlargement of upper cervical glands and a purulent .discharge from the right ear. The temperature was 104 ~ 1~. The secondary infection, under sulfonamide treatment, showed rapid improvement. The temperature went down to 100 ~ F. after twenty-four hours. Uneventful recovery followed. CASE 2 (Table I, Case 4 9 ) . - - t ( . O'D., 7 months of age, was a d m i t t e d J u n e 19, 1943. The eczema had started at the age of 10 days and had gradually become worse. About two weeks prior to admission pustular lesions had appeared on the face. On admission the child presented a severe eczema of face, arms, and legs. The lesions were covered with numerous pustules, many of them having a smallpoxlike appearance. The whole left side of the face was eroded and turnad into one crusted and purulent mass. The general condition was relatively good. The next day the temperature rose to 105 ~ F.; the child appeared seriously ill. I n spite of treatment with sulfathiazole, the high fever continued until J u n e 22. On t h a t day su]fadiazine was instituted in the afternoon. The child began to improve; the temperature subsequently did not go over 100 ~ F: Recovery was rapid. Later a partial paralysis of one foot ,developed which the attending physician thought to be a consequence of infantile paralysis. However, there was no history of any other previous infection. I n view of the fact t h a t the virus of herpes simplex is a neurotroplc virus, the possibility exists that the paralysis might h a v e ' b e e n a consequence of t h a t infection. CaSE 3 (Table I, Case 7 3 ) . - - J . Z., 8 months of age, was admitted Nov. 15, 1943. Eczema started at the age of 2 months. Three days prior to admission ~'pimples ~ began to. appear which spread to the neck, arr0s i hands, and legs. They looked like "chickenpox b l i s t e r s . ' ' The child had been extremely irritable for the past four days. On admission he was found to be suffering from infantile eczema (atopic dermatitis) with the typical umbilieate,d lesions of Kaposi's varicelliform eruption. The temperature was 104.4 ~ F. Treatmeat was started with su]fadiazine. The fever, subsided but rose again a f t e r two days and almost reached 105 ~ F. Sulfa~hiazole was then instituted and the temperature gradually came down within forty-eight hours. The child improved slowly. There was further elevation of temperature up to 102 ~ F. during the next six days. The course in the last two cases was very alarming. respond to su]fonamides in the manner

The children

f e v e r a n d c r i t i c a l c o n d i t i o n c o n t i n u e d i n s p i t e of a d e q u a t e

dosage.

indicate

a beneficial action of the sulfonamides;

The

One had the

impression that the disease ran its course in spite of the sulfonamides. case might

did not

t h a t p y o g e n i e i n f e c t i o n s u s u a l l y do.

The first

they were helpful

544

THE

JOURNAL

OF

PEDIATRICS

TABLE

I.

MORBIDI~1

AGE CASE

IIOSPITAL NO.

DIAGNOSIS

SEX Y[ISSION DAYS YR.

M0.

WK.

Atopie Dermatit~ 1

48940

M

2

Jan.

8

Atopic dermatitis

2 3

50260 58665

M F

11 5

Jan. Jan.

3 8

Atopic dermatitis Atopic dermatitis

4 5 6 7

51432 56032 51585 60963

M F M F

JaU.

20

8 9 10 11

61526 60484 58869 61672

]P M M F

12 13 14 15 16 17 18 19 20

53852 56388 56387 56399 61762 61892 59018 59175 53919

M M F M F M M F M

21 22 23 24

56556 55342 45575 51903

M M F F

25

59353

2 1 1

41 15

Atopie Atopic Atopie Atopie

dermatitis ,dermatitis + intertrigo dermatitis dermatitis + seborrheie dermatitis

Feb. Feb. Feb. Feb.

8 7 9 11

Atopic Atopic Atopic Atopie

dermatitis + seborrheia dermatitis dermatitis + seborrheic dermatitis dermatitis dermatitis + seborrheie dermatitis

9 9 6 4

Feb. March March March March March March March March

13 25 26 18 11 21 25 27 37

Atopic Atopie Atopie Atopic Atopic Atopic Atopic Atopi~ Atopic

dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis + seborrheie dermatitis dermatitis

6 9 5

April April April April

20 18 24 16

Atopic Atopic Atopie Atopic

dermatitis dermatitis dermatitis dermatitis

M

11

April

17

Atopic dermatitis

26 27 28

59394 56641 59205

M M F

8 6

April AprH April

27 18 25

Atopie dermatitis Atopie dermatitis Atoplc dermatitis

29 30 31 32 33 34

59215 59207 49780 51882 56647 59018

F M M M M M

6 4 2 6 4 11

April April April April April May

30 22 24 17 20 20

Atoplc Atopie Atopic Atopic Atopic Atopic

35

52176

M

10

May

18

Atopie dermatitis

36 37 38 39 40 41 42 43 44 45 46

52099 45861 59457 59472 56809 62157 62158 54272 62315 52221 56970

M M M F M M M M F F M

7 9 7 7 5 7 11 4 5 7

May May May May May May May May May June June

3 40 21 29 7 9 5 23 10 14 6

Atople Atopie Atopie Atopie Atopie Atopic Atopic Atopie Atop~c Atopie Atopie

47

54536

M

5

June

12

Atopic dermatitis

1 1 1 2

1

8 3 3

Jan. Feb. Feb.

4 5 4 3 6 4

1

2

1 1 1

1 1 1

8

dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis

dermatitis + seborrheie dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis + seborrheie dermatitis dermatitis dm~matitis dermatitis dermatitis dermatitis

EPSTEIN:

I~ ~I~FANTILE

HOSPITAL

MORBIDITY

AND

MORTALITY

OF

ECZEMA

545

ECZEMA

HIGHEST

I

A I TEMP~RA-I r~UFER "1 TUBE o 7. I

BLOOD C O U N T

*

_

DAY

BIN

(

-

LIoNs

~7HITE

I~EUTROPHILES

(%)

CO~IPLICATIONS LYMPHO EOSIbTO" I PHILES CYTES [r .

(%)

ON

ADhIISSION

AT

PiOSPITAI~

~Vo)

INTERNAL TREAT~r ~VITII SULFONAh~IDES

f

@sos 1 to 78) 101.2 100.2

Intestinal fection

98.8 99.2

99.6 101.8

109 ~" 13.5

4.1 4.3

19.250 11.200

51 25

42 60

6 8

98.4 98.8 98.4 100.2

102.6 100.2 101.2 ]01

10.9 '~" 12.5 8.5 .2 11.3

4.1 4.9 4.6 3.4

9.300 14.400 20.600 11.300

38 61 43 25

51 30 21 53

8 5 36 16

100.6 99.8 99.4 98

99.6 100.2 99.2 101.2

12.5 13.3 11.3 13.1

3.7 4.9 4.0 3.9

11.150 10.750 15.700 13.250

16

66

11

100.2 99.4 99.4 99.4 99.6 100. 99.6 99.4 104.4

102.6 101.4 100.6 100.6 99.8 100.4 100.2 100. 104.6

11.1 8.8 9.0 13.9 11.6 13.1 12.3 13.1 10.4

3.8 4.8 4.6 4.4 4.4 5.4 4.6 4.7 3.8

100.2 98.6 99. 99.4

101.6 102.4 101.4 99.6

9.9 12.9 10.9 ~ 12.7

100.2

103.6

98.8 99.4 103.

inGastrointestinal upset Cold

Streptococcic impetigo

Erysipelas

X

Cold Rickets I n t e s t i n a l infection

9

22

1

12.450 16.400 10.1 8.850 16.000 12.500 8.200 16.100 11.350

38 22 21 30

56 57 70 58

6 16 5 5

Furunculosis

34 20 18 65

53 68 60 28

10 7 19 2

Impetigo

5.1 4.8 5.1 4.1

10.650 24.300 15.000 12.650

44 18 48 33

42 64 51 52

9 8

10.9

5.2

]6.800

99.8 99.8 104.6

11.1 12.5 11.7

4.7 4.3 4.8

19.100 7.750 32.650

30 38 76

44 48 19

20 10

101.2 99.2 98.4 99.8 98.8 100.2

102.4 102.2 100. 100.2 100.2 100.

9.1 12.1 9.3 ~ 8.8 9.3 16.3

3,9 4.7 4.1 3.8 4.1 4.]

23.350 26.350 12.600 15.200 ]9.500 13.700

47 20 35 11 64 24

28 68 48 19 3] ~4

19 10 16 68 1 5

98.2

103.

9,7

3.4

13.200

35

49

15

Allergic bronchitis I n t e s t i n a l infection

99.6 100.2 99.6 99.6 99.6 99.6 101.8 98.8 98.8 101.2 100.6

99.4 100. 101.4 100.2 100.2 100.6 101.8 101.4 99.6 99.8 103.2

10.9 ~ 10.8 10.2 10.2 12.1 12.7 13.5 16.3 11.9 11.3

4.0 4.2 3.1 3.8 4.4 4.4 4.2 6.3 4.3 4.1

16.750 10.950 16.950 K350 13.000 12.400 11.100 21.750 12.150 8.150

65 26 25 32 32 67 24

23 69 71 68 64 30 53

10 5 4

Bronchi.tis

23

40 57

41 38

19 1

99.6

100.2

9.7

4.7

12.150

37

61

I

15

I n t e s t i n a l upset

K u p o s i ~s vuricelliform eruption + otitis media

X

X Cold Diarrhea + impetigo U p p e r respira- Acute tonsillitis tory infection Pyaderma Bronchitis Bronchitis ; u p p e r respiratory infection Urticaria

X X X X

Otitis media

1 Cold Diarrhea A s t h m a ; u p p e r Bronchitis respiratory infection

X

546

T H E JOURNAL OF PEDIATRICS TABLE I-~

AGE

CASE

HOSPITAL NO.

MONTH

HOS-

SEX

DIAGNOSIS YE.

48 49

56964 59834

IV[ F

50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

58038 59657 91353 56338 52237 44629 46606 59018 46172 59936 54794 54832 53016 46636 60893

F ~ F M F M F IV[ F F ~[ M F 1Vi F

65 66

51871 56739

F :[Yf

67 68 69 70

52221 51584 51003 61074

F lV[ :M: M

71 72

52278 60897

73

1Y~O. WK. 5 7

June June

7 30

Atopie d e r m a t i t i s Atopic d e r m a t i t i s

2

8 8 6 2 7 42 8 12 42 6 47 30 9 18 22

Atopic A~opie Atoplc Atopir Ar Atopic Atopic

8

June June June June June June June July July July July July Sept. Sept. Oct.

Atopie A t o p ie Atopic Atopic Atopic Aiopic Atopic

6 5

Oct. Oct.

9 30

A t o p i c d e r m a t i t i s + seborrheie dermatitis A t o p i c d e r m a t i t i s + seborrheic dermatitis

10

Oct. Nov. Nov. Nov.

26 5 5 19

Atopie Atopic Atopic Atopic

M F

5 6

Nov. Nov.

14 20

A t o p i e d e r m a t i t i s + seborrheie dermatitis A_tepic d e r m a t i t i s

61007

M

8

Nov.

33

Atopie d e r m a t i t i s

74

51080

F

Nov.

11

Atopic d e r m a t i t i s

75

55554

l~

Nov.

33

Atopie d o r m a t i t i s

1 4 3 7 9 1 1

1 8 10

1 2 9 1

2 1 1

1 8

s

dermatitis dermatitis d e r m a t i t i s + seborrheie dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis dermatitis d e r m a t i t i s + contae~ d e r m a t i t i s dermatitis dermatitis dermatitis dermatitis dermatitis + intertrigo

dermatitis dermatitis dermatitis dermatitis + acute dermatitis

76 77 78

53458 F 3 Dee. 17 A t o p i c d e r m a t i t i s + seborrheie dermatitis 61173 M 8 Dec, 11 A t o p i e d e r m a t i t i s + seborrheie dermatitis 61214 F 1 Dec. 10 Atopie dermatitis + acute dermatitis *In t h e s e c a s e s the hemoglobin originally h a d been m e a s u r e d in per cent (Tallqvist). F o r the s a k e of u n i f o r m i t y it h a s been c h a n g e d to g r a m s on this b a s i s : 15:5 g r a m s ~- 100 per cent.

in regard to sulfonamides sulfonamides indicated on

the otitis media. Opinions are divided in r e g a r d to the value of in this condition2, 7 Although it seems doubtful whether the exercise any effect upon the original virus disease, their use seems account of complicating pyogenic infections. BLOOD COUNT

The blood count (Table V I I ) has not shown any significant difference between atopic and nonatopie eczemas, except for the eosinophiles. Mild or marked anemia is not infrequent in severe atopic dermatitis of infants, especially when they have been kept for a prolonged period on a restricted diet. However, in my material, anemia was found just as often in children with skin diseases other than eczema without predisposing them to similar complications.

EPSTEIN:

547

HOSPITAL MORBIDITY AND MORTALITY OF ECZEMA

~0I~T'I) HIGHEST TEMPERAl ~ FERA- T U E E o F. ~flEE ON AETEI% hpiqISAD1V[ISttEI~ORED ~tON o F. SION GL0(I'r BIN LIONS) DAY f

100. 100.6

100. 105.4

99.6 98.6 98.6 99.2 101.2 100.4 100.6 97.8 99. 98.2 98.8 100.2 100. 99.6 101.6

100. 100. 99.2 99.6 102.6 100.2 105. 101. 100.2 100.6 100.6 100. 99. 100.4 102.8

98.4 99.4

99.8 99.4

100.4 98.8 100. 101.2

13.3 11.1

BLOOD COUNT

NEU-

W}IITE

TI%0-

LYMPII0-

PHILES

CYTES

(%)

(%)

24 32

66 67

6 1

(%)

4.5 4.4

21.550 ]5.450

INTERNAL

COMPLICATIONS

EOSIN0PHILES

]2.7 11.1 11.9 10.4 12.9 11.6 ~ 10.9 ~ ]2.7 11.6 ~ 12.1 9.4 ]3.5 12.7 9.3 ~ ]0.8

5.1 5.1 3.9 3.5 3.9 4.7 3.7 4.3 5. 4.1 3. 5.2 3.9 4. 4.5

10.550 6.200 ]4.250 14.800 9.450 ]].950 10.250 9.650 16.750 12.500 14.600 12.250 9.500 13.900 14.450

33 55 7 57 50 59 33 47 37 31 39 30 33 51

63 37 58 33 48 40 50 34 51 53 49 65 55 34

11 6 29 8 2 1 12 18 7 16 7 5 11 9

12.7 ]0.1

4.4 4.2

]2.600 11.650

35 21

57 07

8 8

104.4 ]00.4 100. 100.2

8.5 9.3 a 10.9 ~ 13.7

3.2 4.9 4.1 4.6

8.800 11.450 8.300 11.850

51 65 58

36 32 28

10 3 7

99.6 99.6

100.6 102.8

11.1 1].9

4.1 4.3

9.100 10.600

17 30

77 54

6 15

104.4

104.8

10.0

5.3

8.850

51

41

1

99.2

100.

11.6 ~-

3.9

17.550

38

50

10

98.2

103.8

]1.9

4.8

13.500

34

48

99.2 100.2 100.

101. 100.2 100.4

12.3 8.9 12.7

3.3 4.7 5.3

9.100 19.850 14.100

47

32

18

28

70

1

O N AI)IV[ISSION

AT l q O S P I T A L

Asthma ; Kaposi's wrieel]iform eruption Bronchitis

TREATMENT WITH SUL-

FONA)/[. IDES

X

Impetigo

X

Impetigo Pyoderma Asthma

Upper respiratory infection Gastrointestinal upset Otitismedia

X X X

Impetigo, pyodermas Cold Cold; intestinal upset K a p o s i ' s varicelliform eruption Streptococcic impetigo

X Intestinal infection Bronchitis; diarrhea

X

DISCUSSION AND CO1VLMENTS

1. Hospital Morbidity of Infantile Eczema.--1VIy s t a t i s t i c s , complications

o f 23 p e r c e n t

among hospitalized eczema infants, confirm the high morbidity

this condition as reported by several authors

of

(Table VIII).

Even if our figures, like those of G]aser and Edwards, 2 are far below those of the other two authors, they are still vei T impressive. why the variations

of t h e m o r b i d i t y

r a t e a r e so g r e a t .

which infants with eczema are managed some places than

at others.

tion in some instances. that apparently

The conditions

under

are more favorable to cross-infection at

complications

may have escaped the atten-

However, the temperature

data in my statistics indicate

no serious complications

To the question, "Why this paper

Minor

We can only speculate

do children

gives a definite answer.

have been overlooked. with eczema develop complications ?"

548

THE JOURNAL OF PEDIATRICS TAB~

AGE C~E

HOSPITAL NO.

MONTH OF ADMISSION

SEX YR.

M0.

1

11 1

HOSPITAL

DIAGNOSIS

DA~S

WK. Other Eczemws--Cases

79 80 81 82 83 84 85

58646 53747 51565 45499 61870 49908 56648

F I~ F F M ]o F

86

51928

M

87 88 89 90 91 92 93

53889 62103 56846 49993 54341 59679 59950

M F M M M F M

94 95

53166 59286

F M

96 97 98 99 100

49908 61096 61099 59486 55685

F M F IV~ M

*See footnote,

Table

6 3 4 7 10 8 5 2 2 10 2 2 6 2 1

4 7 6 5 6 5

79 to 100 ~

Jan. Feb. Feb. March March April April

5 7 19 8 17 68 3

Seborrheie deI~matitis C o n t a c t ,dermatitis ( e p i d e r m i t i s ) Intertrigo Seborrheic d e r m a t i t i s Seborrheie d e r m a t i t i s Seborrheic d e r m a t i t i s + i n t e r t r i g o Dermatitis

April

14

Seborrheie d e r m a t i t i s

April April May May May June July

24 5 12 7 12 2 3

Intertrigo Contact dermatitis (epidermitis) Contact d e r m a t i t i s ? ( e p i d e r m i t i s ) Seborrheie d e r m a t i t i s .~ Contact dermatitis (epidermitis) Contact d e r m a t i t i s ? ( e p i d e r m i t i s ) Contact dermatitis (epidermitis)

Oct. Oct.

4 31

Dermatitis Seborrheie d e r m a t i t i s ?

Oct. Nov. Nov. Nov. Nov.

9 23 5 25 24

Seborrheic ,dermatitis Seborrheic ~]ermatitis Seborrheic d e r m a t i t i s Intertrigo Intertrigo

I.

We have noted two kinds of complications (Tables V and V I ) : skin infection on one side, and respiratory and gastrointestinal disturbances on the other. In regard to the first group, skin infections such as impetigo, pyodermas, and others, there can be no doubt that the diseased skin is responsible. The type of eczema is apparently of no importance. These secondary skin infections arc common in eczematous children before hospitalization. Among hospitalized infants, the incidence of additional skin infections is negligible. But when it comes to respiratory and gastrointestinal disturbances, the story is entirely different. These are the complications that plague the wards, because they are acquired largely at the hospital. They occur nearly exclusively among the atopie children. There were twenty-two such complications among seventy-eight children with atopic dermatitis and only one among twenty-two children with nonatopie eczemas. It is, therefore, evident that it is not the diseased skin that predisposes the children to these infections. What, then, makes the atopie child so susceptible to these complications ? The answer is the atopic constitution. It is the capacity of the atopie individual to develop other atopie sensitivities, especially of the respiratory and gastrointestinal tracts. It is well known that infants with atopie dermatitis suffer frequently from major or minor respiratory allergies. Gastrointestinal allergies also play an important role in atopic infants, apparently more than is generally realized. A careful history of the babies with infantile eczema often reveals a story of previous intestinal upsets, apparently due to some food intolerance. Minor degrees of food allergy may be manifested only by flatulence or more frequent and foul-smelling stools. The allergic nature of these symptoms is well known

EPSTEIN:

HOSPITAL MORBIDITY AND MORTALITY OF ECZEMA

BLOOD COUNT

sION o F.

TURE

o F.

GLO- (MIL- WHITE BIN LIONS)

97.8 97.2 100.2 99.8 104.6 100. 99.

99.6 100.4 100.4 100.4 100. 100. 100.8

10.4 11.9 9.3* 10.1" 12.3 10.9 12.3

4.8 5.1 4. 5.1 4.5 4.2 4.9

10.800 9.100 8.200 17.850 12.600 12.600 6.900

101.6

]02.2

10.8

4.4

14.370

] 01.2 99. 99. 99.2 98. 99.6 99.2

100.4 99.6 100. 99.4 99.8 99.6 99.4

9.7 14.8 10.2 7.8 x" 12.7 21.7

2.4 4.6 3.8 3. 3.2 5.8

5.650 9.950 13.000 16.050 10.250 9.700

98.4 99.

99.7 102.8

13.5 8.2

4. 3.5

14.700 12.950

98.2 101. 98.6 99.8 99.2

99.2 101.2 100.2 100. 100.

10.9" 11.3 12.9 8.5 12.3

4. 4.2 4.5 4.7 4.6

11.900 10.450 11.150 12.400 13.750

NEULYI~pttO - EOSINOTEOPHILES CYTES PttIEES ON ADMISSION

(%)

(%)

(%)

19 64 34

67 32 58

7 4 5

63 36

49 54

4 6

57 15 29

40 68 52

8 12

45 35

67 47

4 10

Scabies

X X Staphylococcic impetigo Streptococcic impetigo Erysipelas Pyoderma Acrodynla? Staphylococcic impetigo Impetiglnized Scabies

35 60 24 52

INTERNAL TEEATMENT WITH AT tIOSPITAL SULFONA1VLIDES

COMPLICATIONS

fl~NiFERA- ttIGI-I-

~UEE ON EST HEMO- P~ED ApMIS- TE5~'PEI~A-

549

65 26 68 45

5 3

Coryza

X

U p p e r respiratory infection

X X X

Pyoderma Impetigo

as f a r as adults are concerned. The role they p l a y in atopie children was brought to m y attention r a t h e r accidentally. I noticed that our head nurse fondly nicknamed m a n y of m y infants with eczema " S t i n k y . " These babies had f r e q u e n t stools of a peculiar odor. I n most instances we were able to demonstrate a food allergy and to straighten out the affair by dietary restrictions. I t thus becomes r a t h e r simple to explain the hospital complications of the atopic child. These children suffer at the same time f r o m r e s p i r a t o r y and gastrointestinal allergies , which remain subclinical in some instances; like Other patients with these allergies they are more prone t h a n normal people to acquire bacterial infections of the r e s p i r a t o r y and gastrointestinal system. W h a t clinically impresses us as a new disorder actually is an exacerbation or complication of the u n d e r l y i n g process. These chil&ren develop at the hospital the same res p i r a t o r y and gastrointestinal complications as at home (Tables V and V I ) . Th~s explanation seems r a t h e r satisfactory to me. Recognition of these respiratory and gastrointestinal infections as atopic complications indicates t h a t even the best precautions instituted at the hospital m a y not completely eliminate the morbidity of infantile eczema of the atopic type. I n these children the external infection a p p a r e n t l y plays only a minor part. E v e n so, we m a y expect that methods to cut down the danger of crossinfections in a hospital will also decrease the rate of complications in atopic children. 2. Hospital Mortality of Infantile Eczema.--There are only a few statistics about hospital mortality of infantile eczema. Koch and Schwartz 1 reported a mortality rate of 14.5 per cent, Glaser and Edwards, 2 4.7 per cent, Schwartz-

550

T H E J O U R N A L OF PEDIATRICS TABLE III. MOKBIDITY

AGE HOSPITAL CASE NO.

N[ONTII HOS- [ OF ADMIS- P I T A L [ SION DAYS

SEX YR.

1~I0.

DIAGNOSIS

WK.

Erysipelas 1 2 3 4 5 6

45480 45670 43461 62280 46128 48203

M IV[ F F F

1

March April May May July October

8 1 1 1

5 8 3

4 41 6 5 7 7

Erysipelas Erysipelas Erysipelas Erysipelas Erysipelas Erysipelas

Impetigo + Pyodermas 7 8 9 10 11 12 13 ]4 15 16

52565 49896 51986 61847 91477 45499 55417 54733 45296 46080

F lV[ F F lW F M M M

2 2 2 2 1 1

5 7 11

1 6 1

March Aprl] April April June July Oct. Nov. Feb. July

4 5 10 10 2 4 6 13 8 6

Impetigo + pyoderma I m p e t i g o - staphylococcic I m p e t i g o - streptococcic, p y o d e r m a I m p e t i g o - staphylococcic I m p e t i g o - staphylococcic I m p e t i g o - staphylococcic I m p e t i g o - streptococcic Impetigo Impetiginized herpes IIerpes, s e c o n d a r y i n f e c t i o n

Varia 17 18 19 20 21

59534

/~

:F 59534 lV[ 1 53315 M 1 62264 ~r 54013 *See footnote, Table I.

3

Ys

11

Infected hemangiomas

3 6

May June Hay March

10 3 5 9

Infected hemangiomas Urticaria Y a c c i n i a generalized Toxicoderma

1

man and associates, 3 3.3 per cent. In our one hundred cases treated at St. Joseph's Hospital there was no death. I t is somewhat disappointing for the dermatologist that he cannot claim any credit for this result. In my opinion the fortunate outcome is due mainly to two factors: in the first place, and chiefly, to the sulfonamides; and in the second place, and to some extent, also to the excellent care of our nursing staff. The beneficial effect of the su]fonamides in respiratory infections is too obvious as to require discussion. Twenty-two infants in our series received sulfonamide therapy. The excellent nursing care afforded to the infants with infantile eczema must be stressed. We have been f o r t u n a t e to have throughout these years the same very competent supervisor of the pediatric ward. This Sister has not only become an expert in handling infants with infantile eczema, but also they have become her pets and are as closely watched as can be. Although the dermatologist is in charge of all children with infantile eczema , they are all examined by the pediatrician. The latter is called in again routinely w h e n the slightest complication arises. Furthermore, whenever feasible, the eczematous children are separated from the other pediatric patients. Care is taken that these children are not exposed to d r a f t and not chilled d u r i n g treatment. An electric heater is placed near them. The infants are usually treated by the same nurses who are especially assigned for this work. The significant point of my statistics seems to me that since the advent of the sulfonamides, death from eczema has become an avoidable complication. I n order to demonstrate that point I shall analyze briefly the instances of death

01~ 8~I~

EPSTEIN:

HOSPITAL MORBIDITY AND MORTALITY 0F ECZEMA

r

"I$1~ASES OTHEI~ T H A N ECZEMA V CO1VIPLICATIOHS

BLOOD COUHT

fffBE0N

ttlGHEST TEM:PERA" HEM0-J R,ED ] TUF~E o F. GLO- ( M I L -

jlOI~ ~ F.

BIN

WHITE

LIONS)

HEUTROPtlILES

(%)

Zu163 EOSINOPHO-

PHILES

(%)

(%)

CYTES

ON ADIv[ISS[0N

AT H O S P I T A L

INTEKHAL TKEATI,s WIT]L SULFONAS[IDE S

f

104:.4 103.4 106. 105.6 t03.6 102.

104:.4 105.4 105.6 101. 103. 100.4

99.6 99.4 ]00. 98.6 99.2 10410].2 98.4: 99. 101.8

9.3*

4.

10.6 ]0.9* 10.9"

99.4: 99.8 100.4 99.8 99.8 ]03. 99.8 100.4: 99. 100.8

104.6

105.

102.2 102.4 104.4 98.

103.6 100.4 103.8 99.4

Abscesses

8.600

29

71

4.7 4.0 4.5

17.850 10.000 9.]00

74: 4:0

16 60

13.1 9.3* 11.5 16.0 ]0.4: 1L6" 11.7 12.1

4:.3 2.4: 4,2 5.0 5.2 4:.0 3.6 4.0

10.300 8.050 17.050 35.200 6.250 5.750 5.000 8.250

63 59 73 72 61 45

33 4:1 24 21 36 50

11.6"

4:.5

7.000

10.0

3.4

30.950

73

20

1

9.4 8.9 9.1

3.7 4.4

26.350 5.550 1].800

65 39 36

32 58 61

1 1

2

X X X X X X

3 2 3 X

Streptococcic sore t h r o a t Nephritis

X X

from eczema as reported in the literature. F o r this purpose we may divide them into three groups: (1) death in children with eczema admitted to the hospital with severe complications, (2) death in children with eczema admitted without complications, (3) the so-called " s u d d e n d e a t h " from eczema ( " E k z e m t o d " of the German literature). 1. Death From Pre-existing Complications.--It does not seem p r o p e r to place the responsibility for the fatal outcome in these cases on the eczema or the hospital. F o r instance, two patients (Cases 34 and 60 of Glaser and Edwards 2) with eczema and suffering from erysipelas and pneumonia, respectively, died shortly after admission to the hospital. It is safe to assume that they would also have done so if they had been left at home. In fact, all of G]aser and E d w a r d s ' deaths from eczema occurred among children admitted with eomplications. Their actual hospital mortality rate for children hospitalized only on account of eczema is zero. This report is the only one covering the sulfonamide era. It indicates that the mortality even among children admitted with complications can be praetically eliminated, because the most dangerous of these, severe respiratory infection and erysipelas, are well controlled by the sulfonamides. The change brought about by these drugs is well demonstrated in our erysipelas series (Table I I I ) . The former high infantile mortality from this infection is well known. All six children w i t h erysipelas recovered--undoubtedly due to sulfanilamide.

2. Death in Eczematous Children Arising front Infectious Complications Acquired at the HospitaL--Analyzing these cases we find that practically all

552

TI:IE J O U R N A L

TABLE I V .

OF PEDIATRICS

INCIDENCE OF COMPLICATIONS IN VARIOUS GROUPS OF INFANTS t{0SPITALIZED FOR DERIV[ATOLOGICAL CONDITIONS DIAGNOSIS

NUN[BEt% OF CASES

Atopie dermatitis (see Table I) Other eezemas (see Table II) S k i n d i s e a s e s o t h e r t h a n e c z e m a (see Table III)

78 22 21

TABLE V.

COMPLICATIONS TOTAL FEI% C E N T

22 1 0

28.3 4.5 0

IN~ATURE OF }IoSPITAL-ACQUIRED COMPLICATIONS

INFANTILE

FOI~I~ OF ECZEIVIA

SKIN

GASTROINTESTINAL DISTURBANCES

RESPIRATORY INFECTIONS*

INFECTIONS

A t o p i c d e r m a t i t i s ( C a s e s 1 t o 78) O t h e r e e z e m a s ( C a s e s 79 to 1 0 0 )

OF CHILDREN W I T t I

ECZEI~IA

2 -

12 1

8 -

*Cold, t o n s i l i t i s , o t i t i s m e d i a , b r o n c h i t i s . TABLE

VI. CLASSIFICATION OF COMPLIOATIONS PRESENTED BY TIIE ECZEA{ATOUS INFANTS ADMISSION TO THE IIOSPITAL (THIF~TY-NINE COMPLICATIONS IN THII~TY-SIX INFANTS) SKIN

FORM

OF ECZEIV[A

I%ESPII%AT 01%u

INFECTIONS*

Atopie dermatitis (Cases 1 to 78, T a b l e I ) O t h e r e e z e m a s ( C a s e s 79 to 100, T a b l e I I )

INFECTIONS~

GASTRO-

UPON

O T H E R CO]Y[-

INTESTINAL DISTURBANCES

PLICATIONS~

12

10

3

2

I0

1

-

1

* I m p e t i g o , p y o d e r m a s , f u r u n c l e s , e r y s i p e l a s , scabies, K a p o s i ' s v a r i e e l l i f o r m e r u p t i o n . ~Cold, u p p e r r e s p i r a t o r y i n f e c t i o n s , o t i t i s m e d i a , b r o n c h i t i s , a s t h m a . $Riekets, acrodynia, urticaria.

TABLE V I I .

I~.ESULTS OF BLOOD COUNTS IN ATOFIC' AND 2NONATOPIC' ECZEg~AS ATOPIC E C'ZEI~AS (TABLE I )

TEST

(%)

NONATOPIC EOZE~AS (T~LE II)

CONTROLS: OTttEK SXIN DISEASES (TABLE m )

(%)

(%)

Slight anemia* IYiarked anelnia* Total anemia Leueocytosis (over 12,000)

27.6 32.9 60.5 56.6

9.5 28.6 38.1 47.6

29.4 47.1 76.5 29.4

Lymphocytosis (over 45%) Average eosinophilia

65.2 9.7

71.4 4.9

38.5 0.9

*The f o l l o w i n g v a l u e s w e r e c o n s i d e r e d n o r m a l : l%ed c o u n t 4,200,000; h e m o g l o b i n 11.0 Gin. for e h i l d r e n l e s s t h a n 4 m o n t h s a n d 12.0 Gin. f o r c h i l d r e n o v e r 4 m o n t h s . H e m o g l o b i n r e a d i n g s m o r e t h a n 1.0 Gm. b e l o w the n o r m a l v a l u e s w e r e c o n s i d e r e d a s s i g n s of m a r k e d a n e m i a , e s p e c i a l l y w h e n tile r e d c o u n t w a s a l s o b e l o w n o r m a l . The f i g u r e s f o r n o r m a l v a l u e s a r e s o m e w h a t a r b i t r a r y ; t h e y w e r e b a s e d on t h e a v e r a g e v a l u e s a s g i v e n b y E:racke, 8 a n d b y 2r TABLE V I I I .

MOI~B1DITY OF INFANTILE ECZEMA IN VARIOUS LOCATIONS CONTlgOLS

ECZEM:A--ATOPIC

DERMATITIS

Milwaukee,

Rochester,

Location

Wis. Author

Total number of cases Percentage of hospitalacquired complications

Koch and Schwartz1 103 43.6

N. u Glaser and Edwards2 106 20

(BOARDERS) New N.

York, u

Schwartzmad and associates3 33 60.6

Marshfield, Wis.

100 23

New

York,

N.Y. Schwartzman aad assoeiates~ 111 6.4:

(NONECZEMAS) Marshfield, Wis.

21 0

EPSTEIN:

HOSPITAL lYIORBIDITY AND MORTALITY OF ECZEMA

553

children died f r o m complications that could have been prevented or t h a t would have responded to sulfonamides if they had been available at t h a t time. The statistics of Glaser and Edwards, as well as mine, 'indicate t h a t this cause of death can be actually eliminated with p r o p e r care and especially with the help of the sulfonamides. 3. Suc~en Dec~ts from Ecz~ma.--There remains a group of deaths f r o m eczema t h a t do not fall into the two categories we have mentioned. A certain degree of m y s t e r y cloaks these cases. They are usually relented to as " s u d d e n death f r o m eczema," corresponding to the " E k z e m t o d " of the German literature. These deaths are reported to occur v e r y suddenly a n d no cause f o r them can be found. They have been known for over a century and also have been reported recently (Davies'~ They have occurred in and out of the hospitals. Many experienced dermatologists (Jadassohn 11) have never seen them. I, too, cannot recollect ever having come across one. However, the authenticity of the reports cannot be doubted. M a n y theories have been advanced, most investigators presenting r a t h e r one-sided ideas based on t,he one or r a t h e r few cases of their own experience. To be sure, all cases so reported are not alike. Quite a few can be definitely explained, by the clinical course or the pathologic findings, as due to infectious complications. B u t there remains a definite entity of sudden death f r o m eczema without explanation. The t e r m sudden " d e a t h " is somewhat misleading, as some children experience similar crises f r o m which they recover. Davies 1~ described these incidents as follows: The accident is peculiar to infants with infantile eczema. I t occurs during the first y e a r of life. Most of the cases occur in the spring. Nearly all, if not all, take place in hospitals or away f r o m the mother. The accidents usually occur within the first few days of hospitalization. Autopsy does not disclose sufficient cause of death. These incidents a p p a r e n t l y occur when the babies are in the care of some

physicians and not of others. According to Davies usually the first definite change noticed is restlessness and pallor with or without cyanosis. D y s p n e a soon becomes obvious a n d m a y be intense. Vomiting also is frequent and convulsions m a y occur. The t e m p e r a t u r e rises r a p i d l y to 103 ~ F. or more. The i n f a n t becomes collapsed and unconscious; the lips are blue; t]~e skin, rigid; and the extremities, cold. Death occurs rapidly. However, according to Davies 1~ not all these accidents terminate fatally. Some patients have recovered. The child m a y even become comatose and yet the following day present a normal aspect and take his food as usual. Many theories have been proposed. BernheimKarrer; ~z basing his opinion on findings of one case of his observation, would like to explain the death as due to an refections myocarditis. However, in his ease there was secondary pyogenic infection of the eczema present. F e e t ~ considered status thymolymphatieus responsible for the eczema death. Davies ~~ was inclined to think of a psychic t r a u m a . Schwartz 1~ analyzing ten eczema deaths, believed t h a t f u l m i n a t i n g septicemia might have been the cause; however, m a n y of his cases a p p a r e n t l y do not belong to the group here u n d e r discussion. H u t i n e l ~ considered anaphylaetic shock. More ~ thought of disturbances in the p a r a s y m p a t h e t i c nervous system ("Vagustod"). Moro p o i n t e d out that most of the deaths in F e e r ' s and his statistics had occurred in the early months of the year. However, Moro considered the vagotonic factor only p a r t of the picture. H e believed t h a t local t r e a t m e n t was also responsible. lVIoro warned, therefore, against extensive external t r e a t m e n t of eczema in the spring.

OP5~

THE JOURNAL OF PEDIATRICS

F r o m early times, t r e a t m e n t of the eczema has been considered a causal factor, because the death occurred a f t e r local t r e a t m e n t was instituted. The children with eczema were considered noli m e tangere by Steiner 1~ in the early nineteenth century. But even in modern times external t r e a t m e n t is considered a factor in these accidents. I n t e r f e r e n c e with cutaneous respiration b y ointments covering the whole body had been suggested by Bloch, Simon, and Castendoz is and b y Cameron. 1~ Sulzberger 2~ suggested the possibility of poisoning f r o m phenollike t a r products. According to Meyer and Gottlieb, ~1 phenol poisoning leads to paralysis of the central nervous system. I t begins with vertigo, headache, vomiting. I n severe cases eyanosis follows after a few hours, with cold sweats, small, frequent pulse, collapse. The outcome is either death or r a p i d complete recovery. A comparison of this description with that of sudden death f r o m eczema as given by Davies, 1~ reveals a great resemblance of the two conditions. Sulzberger ~~ stressed the fact that t r e a t m e n t of these children is frequently carried out in general wards with supervisors not familiar with the special problem. T a r is a rather toxic product and should not be used on too large a surface. Still some hospitalized children are treated with t a r or t a r ointment all over the body. One must remember that phenol is very r a p i d t y absorbed f r o m the skin. Phenol is m u c h more toxic when it enters the body through the skin t h a n when taken orally because it enters the circulation without passing through the liver. The liver detoxifies the phenol by forming conjugated sulfuric and glyeuronic acids. Such a toxic t h e o r y - - e s p e c i a l l y in combination with interference with cutaneous respiration and labiIity of the autonomous nervous s y s t e m - - w o u l d explain satisfactorily the symptoms as well as the other circumstances of some of the acute deaths f r o m eczema. I t would also explain why these eases of eczema deaths occur only in some hospitals o r with some doctors and not with others. The iaek of post-mortem findings also fits in well with this theory. There are no pathologic changes characteristic of acute phenol poisoning. I have stressed this point, in spite of its hypothetical nature, because we are not fully aware of the toxicity and dangers f r o m treatment with coal tar. I t is important, especially in children, not to use t a r over too great a surface, especially if this surface is eroded. I t is a good rule to use t a r on not more t h a n two extremities at a time. SUMMARY AND CONCLUSIONS

1: Among one h u n d r e d consecutive hospital admissions of infants with eczema, f r o m 1937 to 1944, no deaths occurred. 2. Out of these one hundred children, twenty-one suffered f r o m twentythree complications, a morbidity of 23 per cent. 3. A breakdown of the statistics showed that all but one of the complications occurred among the seventy-eight atopic children and only one among the twenty-two nonatopic eczemas. 4. Nearly all complications were respiratory infections or gastrointestinal disturbances. They are explained as exacerbations of concomitant r e s p i r a t o r y or gastrointestinal allergy. 5. The statistics presented demonstrate that with the advent of sulfonamides and u n d e r p r o p e r nursing care, there need not be fear of death in hospitalized infants with eczema. This conclusion should not lead to indiscriminate hospitalization of cases of infantile eczema, but it should eliminate f e a r in those instances where hospitalization becomes m a n d a t o r y on account of the s e v e r i t y of the eczema, or for other reasons.

LAPIN:

SERUM IN PROPHYLAXIS AND TREATMENT OF WHOOPING COUGH

555

6. The so-called "sudden death from eczema" is discussed. A hypothesis of toxic effects from phenollike tar products, in combination with interference with skin respiration and disturbance of the autonomous nervous system, is suggested to explain some instances of this phenomenon. A reminder is given about the toxicity of coal tar and it is suggested that tar preparations should not be used over too great surfaces. I am indebted to Dr. Jerome Glaser for his suggestion to publish this series and for his friendly advice. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Koch, D., and Schwartz, A. B.: J-. PEDI~-T. 2: 169, 1933. Glaser~ J., and Edwards, W. 3/1[.: Am. J. Dis. Child. 60: 526, 1940. Sehwartzman, L, Dragutsky, D., and Rook, @.: Arch. Pedlar. 60: 19, 1943. Barton, 1%. L., mad Brunsting, Louis A.: Arch. Dermat. & Syph. 50: 99, 1944. Lynch, F . W . : I(aposi's u Eruption, Arch. Dermat. & Syph. 5 1 : 1 2 9 , 1945. Wenner, Herbert A.: Am. J. Dis. Child 67: 2~:7, 1944. Connor, A., a~d Gonee~ J. E., J r . : 3% P~I)tAT. 23: 335, 1943. t(racke, Roy R.: Diseases of the Blood, ed. 2, Philadelphia, London, Montreal, 1941, J. B. Ldpplneott Company, p. 118. Mackay, Helen (Quoted from Cooley, Thomas B.: The Anemias) : I n B r e n n e m a n n ' s Practice of Pediatrics, Hagerstown, Md., 1944, W. :F. Prior Company, Inc., vol. 3, chap. 16, p. 7. Davies~ J. It. Twiston: Brit. J. Dermat. 52: 182, 1940. Jadassolm, J . : Quoted from Sehwaf'tz.]4 Bernheim-Karrer, L : Ztschr. f. Kinderh. 35: 120, 1923. Feet, E.: Quoted from Davles.lo Schwartz, A. B.: g. PFA)IA'r. 4: 172, 1934. Itutinel: Quoted from Davies.!o Moro, E.: Miinehem Med. Wchnschr. 67: 657, 1920. Steiner: Quoted from Davies.lo Bloch, Simon, and Castendoz: Quoted from Davies.lo Cameron, tI. C. : Quoted from Kreibich, C. : Ekzeme and Dermatitiden, Handb. d. t t a u t u. Gesehlechtskr. (J. Jadassohn), Berlin, 1927, Julius Springer, vol. 6, part I, p. 54. Sulzberger, M. B.: Discussion of Jerome Glaser, Pediatric Allergy, :First Annual Meeting American College of Allergists, Chicago, June 10, 1944. (Unpublished). Meyer, tI. It., and Gottlieb, R.: Die experlmentelle Pharmakologie als Gru~dlage der Arzneibehandlung, Ber]in-W:ien, 1921, U r b a n & Schwarzenberg~ p. 582. Epstein, S.: Ann. Allergy 2; 247, 1944.

S E R U ~ IN T H E P R O P H Y L A X I S OF CONTACTS AND T H E T R E A T M E N T OF WHOOPING COUGH JOSEPH tI. LAP~,T, M.D. BaoNx, N. Y. HE efficacy of

Hemophilus pertussis

vaccines in the routine prophylaxis of Its acceptance by the medical profession is attested by the recent favorable report of the Council of Pharmacy and Chemistry. 1 In spite of this, there still seems no unanimity on the need for specific serum in the passive immunization of contacts to whooping cough nor in the treatment of the disease. For example, diphtheria toxoid2 and adrenal cortex 3 have been recently advocated for the treatmeat of whooping cough. The use of such nonspeeific agents testifies to the fact that the medical profession is as yet unacquainted with specific serum therapy in pertussis. Such vaccine fractions as Topagen, U.B.A., and Pertussis Antigen (Lederle) have had their day in both prophylaxis and treatment. However,

T whooping cough has been demonstrated in every large series.