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Proceedings Second Annual Meeting of the American Academy of Pediatrics
American Academy of Pediatrics Proceedings SECOND ANNUAL MEETING OF THE AMERICAN ACADEMY OF PEDIATRICS I~RIDAY A F T E R N O O N SESSION
May 13, 1932 Round TaMe Conference o~ Scarlet Fever A Practical Consideration of Skin Tests, Active and Passive Immunization and the Use of Therageutic Antitoxins Leader: John A. Toomey, M.D. ; Assistants: Archibald Hoyne, M.D., and A. Clement Silverman, M.D. I n this seminar, we are a s k e d to consider the s u b j e c t o f scarlet fever. To cover this s u b j e c t completely would t a k e more t i m e t h a n we h a v e at our disposal. Therefore, we h a v e divided it into t h r e e topics as follows: I. Skin T e s t s in Scarlet F e v e r ( I n t r o d u c e d b y Dr. S i l v e r n l a n ) - A. The Dick T e s t B. Sehu]tz C h a r l t o n Reaction O. Conehlsions I L I m m u n i z a t i o n ( I n t r o d u c e d bar Dr. T o o m e y ) - A. Active I m m u n i z a t i o n B. P a s s i v e I m m u n i z a t i o n O. Conclusions I I L T r e a t m e n t ( I n t r o d u c e d by Dr. H o y n e ) - A. The T h e r a p e u t i c U s e of Scarlet F e v e r A n t i t o x i n s B. Conclusions I. Skin Tests in Scarlet l~ever
A. The DivIc T e s t . - - F o r clarity, one need only m e n t i o n t h a t t h e Dick test is a t e s t to d e t e r m i n e t h e s u s c e p t i b i l i t y of a n individual to scarlet fever a n d t h a t its discovery by t h e Dicks h a s b e e n of exceeding i m p o r t a n c e to medicine. M o s t i n d i v i d u a l s who use this t e s t r o u t i n e l y have some d o u b t s as to i t s absolute specificity since m a n y people develop scarlet fever who have h a d n e g a t i v e Dick tests. There are likewise people who have h a d scarlet f e v e r who still h a v e positive Dick t e s t s at t h e end of t h e i r illness 30 d a y s later. I t m i g h t be said of t h e f o r m e r cases t h a t s u c h i n d i v i d u a l s have h a d a n a t u r a l loss of i m m u n i t y , as a r e s u l t of which t h e y h a d become susceptible to scarlet fever. T h a t this c a n n o t always be the case is seen f r o m t h e f a c t t h a t t h e s e p a t i e n t s still h a v e n e g a t i v e Dick t e s t s a t t h e b e g i n n i n g o f the scarlet f e v e r r a s h when, theoretically, t h e y ~hould have positive tests. The a c t u a l p e r c e n t a g e of these n e g a t i v e Dick r e a c t o r s who develop scarlet f e v e r is n o t known, b u t our ex perienee i n d i c a t e s t h a t s u c h cases a r e n o t rare.
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There is another group of scarlet fever patients who never have h a d Dick tests previous to admission to the hospital, but who show negative Dick reactions on admission a t the height of their rash and when theoretically they should have a positive Dick reaction. There are so m a n y of these cases admitted to oar hospitals t h a t the finding of a negative Dick test a t the height of a r a s h cannot be said to rule out scarlet fever. I t is very probable t h a t the r a s h in these instances is caused by ether strains t h a n those originally described as being the sole causes of the disease. Certainly, the s t r a i n t h a t causes scarlet fever one year m a y not be t h a t which causes an epidemic of the disease the succeeding year since the m a j o r i t y of patients of the first year m a y be Dick positive and the m a j o r i t y of the second, Dick negative. DR. E. B. SHAW, S - ~ FR_~NCI~CO, CALI~e~I:~.--I agree with the conclusion of Dr. Silverman a n d ~ i s h to state t h a t in m y experience there was a definite lack of correlation between the blanching findings a n d t h e Dick t e s t itself. I should like to ask whether the Dick test can be definitely stated to be a toxin reaction? The response of the skin to a Dick test is hardly t h e same as a Schick reaction. I t begins promptly and gradually reaches a m a x i m u m i n twenty-four hours. I t is not characterized by the latent period so characteristic of the tissue response to a true toxin, l%rthermore, there has not~ to m y knowledge, been shown the same degree of consistency between the Dick reaction a n d the i m m u n e state to scarlet fever t h a t one encounters with regard to the Schlck reaction and i m m u n i t y to diphtheria. I s not the Dick reaction somewhat intermediate in its n a t u r e between a toxin and a n allergic skin response? DR. J. S. W A L L , WASItING~0~, D. C . - - P e r h a p s the percentage of errors t h a t occur in interpretation e f the Dick test m a y be due to the time of reading the test. I suggest t h a t waiting a day or so more m i g h t reveal a number of delayed reactors. I feel t h a t it m i g h t be very 4iflleult to interpret Dick tests at the height of the rash. DR. A. C. SILVERlVfAN, SYRACUSe, l~aw YORK.--The Schick test differs from the Dick test in t h a t the reaction persists longer. The former material is less stable t h a n the latter. DR. C. A. E A R L E , DES P b A I ~ S , ILLINe]s.--I have given over 11,000 Dick tests during the course of m y work in several institutions. I have seen only one negative Dick reactor develop scarlet fever. All those who have had scarlet fever, in cur e~perience, have always h a d a negative Dick test. I have great confidence in the Dick test as evidence of susceptibility and i m m u n i t y to this disease. There m a y be some physical reason to explain the number of negative Dick tests t h a t occur in m a n y people who should be positive according to the history. DR. 5. A. T O O M E u CLEV~NI~, O~IO.--I think t h a t the Dicks have show~ t h a t m a n y minor apparently innocuous physical t h i n g s m a y cause destruction of the toxin. W h e n one remembers t h a t 1 c.e. of 4 day toxin m a y contain as h i g h as 6,000 or more skin test units, one can u n d e r s t a n d how easily physical reactions m i g h t destroy this minute amount of toxin. Too much alcohol, tincture of iodine, antiseptics of various kinds can vitiate the test. Great pains should be followed in the care of needles and syringes. Both should be dry sterilized, since even the small amount of moisture and water of condensatloa t h a t collects a f t e r cooling m i g h t alter the test reading. P a y i n g attention to all these points, we still have negative Dick test reactors in individuals who should be positive. We feel t h a t the belief t h a t there are only two strains of specific streptococci t h a t cause the disease entity of scarlet fever is entirely erroneous. B. ~gchvltz Charlto~ Reaction.--These authors discovered t h a t convalescent scarlet fever serum injected into the skin of an acutely ill scarlet fever p a t i e n t blanched
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the r a s h a b o u t t h e injection. T h e y concluded t h a t a specific p r o d u c t h a d a p p e a r e d in t h e s e r u m of convalescent p a t i e n t s which b r o u g h t a b o u t a local cure of the disease a n d t h a t t h e r e a c t i o n w a s specific. I t m i g h t be i n t e r e s t i n g to m e n t i o n t h a t t h e specificity a n d t h e w o r t h of a n y a n t i t o x i n is o f t e n g a u g e d b y i t s a b i l i t y to locally b l a n c h t h e r a s h of a n acutely ill s c a r l e t f e v e r p a t i e n t . I f t h i s criterion is true, t h e r e a r e m a n y a n t i t o x i n s now on t h e m a r k e t t h a t a r e w o r t h l e s s since m a n y m e r e l y cause a local i n f l a m m a t o r y reaction a n d l~o~blanching whatever. One cannot s a y t h a t a r a s h is n o t a scarlet f e v e r r a s h j u s t because scarlet f e v e r a n t i t o x i n does n o t ]oca]Iy b l a n c h t h i s rash, f o r we h a v e h a d h u n d r e d s of cases in w h i c h the" r a s h h a s n o t b e e n b l a n c h e d b y scarlet fever a n t i t o x i n a n d h a s been b y eoineidentally i n j e c t e d convalescent scarlet fever serum. T h e s e p a t i e n t s have h a d positive Schultz C h a r l t o n t e s t s with convalescent serum, a n e g a t i v e reaction with scarlet fever a n t i t o x i n s a n d , c u r i o u s l y enough, m a n y h a v e h a d a n e g a t i v e Dick t e s t a t the s a m e time. W e feel t h a t we c a n n o t be too specific a b o u t conclusionu in r e g a r d to t h e Schultz C h a r l t o n p h e n o m e n o n a n d a l t h o u g h a positive Schultz C h a r l t o n p h e n o m e n o n o b t a i n e d w i t h convalescent scarlet f e v e r s e r u m is f a i r l y conclusive, y e t i t s absence does n o t conclusively rule out t h e disease. C. Conch~sio~s.--We feel t h a t t h e Dick tes~ is a very valuable aid in d e t e c t i n g s u s c e p t i b i l i t y to scarlet fever, b u t we do n o t t h i n k t h a t it is a n absolutely p e r f e c t test. W e feel t h a t a n e g a t i v e r e a c t i o n does n o t rule o u t the p o s s i b i l i t y of scarlet fever in i n d i v i d u a l s w i t h s c a r l a t i n a l rashes. W e would say, however, t h a t the exceptions are n o t i n n u m e r a b l e a n d t h a t f o r p r a c t i c a l p u r p o s e s , one could ignore t h e m , merely k e e p i n g i n m i n d t h e l i m i t a t i o n s . A positive Sehnltz C h a r l t o n reaction is good evidence f o r the presence of scarlet fever~ b u t a n e g a t i v e Schultz C h a r l t o n does n o t rule out t h e disease. DR. W A L L - - T h e Schultz C h a r l t o n t e s t s c a n o f t e n be seen a n d a p p r e c i a t e d b e t t e r i f r e a d at a d i s t a n c e r a t h e r t h a n closely. DR. S H A W . - - T h e Schultz C h a r l t o n r e a c t i o n is of no g r e a t value. I t is no good in d o u b t f u l eases a n d c e r t a i n l y n o t needed in t y p i c a l ones. I a g r e e with t h e s p e a k e r w h e n he s t a t e s t h a t convalescent s e r u m gives b e t t e r b l a n c h i n g t h a n antitoxin. DR. T O O M E Y . - - D r . S h a w h a s raised the question of p r a c t i c a b i l i t y of t h e Schultz C h a r l t o n test. W e agree t h a t it is useless in a n y case t h a t h a s a p a p u l a t e d or s p l o t c h y m a e u l a t e d r a s h a n d these u s u a l l y are t h e very r a s h e s a b o u t which we are i n doubt. W c agree, likewise, t h a t t h e r e is .no element of d o u b t in t h e typical scarlet fever case a n d t h e b l a n c h i n g t e s t in t h o s e i n s t a n c e s would be only of a c a d e m i c interest. Dr, S i l v e r m a n s t a t e d t h a t t h e t e s t could n o t be u s e d to rule o u t scarlet f e v e r in a n i n d i v i d u a l who tins a t y p i c a l r a s h . To this we agree, f o r we h a v e seen h u n d r e d s of cases who do n o t b l a n c h w i t h t h e so-called commercial antitoxins. Some of these eases did b l a n c h w i t h convalescent serum. Incidenta]ly, it is quite definite t h a t one c a n n o t sell scarlet fever a n t i t o x i n s on t h e b a s i s of b l a n c h i n g a b i l i t y since ulost of the sera now sold have poor b l a n c h i n g qualities. I f , however, b l a n c h i n g does occur with s e r u m we do n o t see how one could ignore t h e possibilities such a r e a c t i o n indicates. II. I m m u n i z a t i o n A . A c t i v e I m m u n i z a t i o n , W i t h To,r,@, Ma,de F~'om Strep~ocovci.--AlI our practical experience h a s b e e n w i t h t h e u s e of Dick t o x i n as p u t o u t b y t h e Squibb C o m p a n y , t h e originaI licensees u n d e r t h e D i c k s ' p a t e n t . I n the q u e s t i o n of i m m u n i z a t i o n , two t h i n g s have to be considered, the r e s u l t s of i m m u n i z a t i o n a n d t h e possible d a n g e r s t h a t m i g h t occur d u r i n g its use,
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F o r t h e p a s t s e v e n or e i g h t years, one of u s (J. A. T.) h a s b e e n i m m u n i z i n g n u r s e s who e n t e r e d t h e local t r a i n i n g school a n d over 953 s t u d e n t s f o u n d to have positive Dick t e s t s h a v e been g i v e n t h e five i m m u n i z i n g i n j e c t i o n s r e c o m m e n d e d . N o t one of t h e n u r s e s h a d developed scarlet fever. Several e n t r a n t s incompletely i m m u n i z e d have developed t h e disease. T h e Dick test b e c a m e n e g a t i v e in t h e i m m u n i z e d i n d i v i d u a l 10 d a y s to 2 ~m o n t h s a f t e r the l a s t injection. S i m i l a r experiences a r e n o t e d in the literature. Likewise, wo have i n j e c t e d m a n y children with similar results. A r e t h e r e a n y d i s a d v a n t a g e s i n this p r o g r a m ? W e h a v e f o u n d some i n d i v i d u a l s so sensitive to t h e m a t e r i a l t h a t i m m u n i z a t i o n h a d to be d i s c o n t i n u e d a f t e r t h e first or second injection. R e a c t i o n s do occur with i m m u n i z a t i o n p r o g r a m s . A s a m a t t e r of fact~ we h a v e h a d b u t f e w n u r s e s who h a v e n o t h a d some reactions, t h e m i l d e s t of w h i c h were~ local i n f l a m m a t o r y r e s p o n s e s in 70 to 80 per c e n t of t h e g r o u p i m m u n i z e d . A p p r o x i m a t e l y l 0 to 15 per c e n t of t h e s e i n d i v i d u a l s were sick e n o u g h to be confined to b e d f r o m one to t h r e e days. B e c a u s e of t h e s e reactions, we do n o t believe t h a t t h e a d u l t s should ever b e inj e c t e d w i t h o u t a n initial d e t e r m i n a t i o n of t h e i r s e n s i t i v i t y ; i.e., unless t h e y have a positive Dick t e s t . Some s a y t h a t a d u l t s m a y have reactions b u t t h a t children do not, a n d t h a t , therefore, i n j e c t i o n s should be m a d e early, possibly b e t w e e n 2 a n d 5 y e a r s of age arLd m a d e w i t h o u t even d o i n g a Dick test. W e c a n n o t a g r e e with t h e s e e m i n g l y g e n e r a l opinion t h a t children do n o t h a v e r e a c t i o n s since we have h a d local a n d g e n e r a l r e a c t i o n s quite as severe as those seen in a d u l t s ; therefor% we feel t h a t children too, s h o u l d h a v e a d e t e r m i n a t i o n of s u s c e p t i b i l i t y before i n j e c t i o n s are
given. The local r e a c t i o n s r e f e r r e d to. m a y be a n y t h i n g f r o m a simple well d e m a r c a t e d lesion to a n a n g r y i n f l a m m a t o r y response t h a t involves t h e whole arm. T h e g e n e r a l r e a e t i o n s a r e t h o s e t h a t occur w i t h clinical a t t a c k s of scarlet fevei b i.e., vomitlng~ severe p r o s t r a t i o n , h i g h t e m p e r a t u r e , a r t h r i t i s , adenitis, a n d o f t e n enough~ a rash. B e c a u s e of t h e s e reactions, we ~eel t h a t the. m e t h o d should be utilized to. imm u n i z e a ~ i v e l y only t h o s e i n d i v i d u a l s who m a y experience m a s s i v e exposure in t h e i r work; i.e., n u r s e s a n d doctors w o r k i n g i n c o n t a g i o u s h o s p i t a l s or children in i n s t i t u t i o n s . W e do n o t feel t h a t t h e p r o c e d u r e should be a d o p t e d as ~ public h e a l t h m e a s u r e since f u r t h e r work will have to b e done to create a m o r e i n n o c u o u s product. One m u s t r e m e m b e r also t h a t active i m m u n i z a t i o n does n o t necessarily give b a c t e r i a l i m m u n i t y , so t h a t a person w h o either h a s h a d scarlet f e v e r or h a s bee~l actively i m m u n i z e d a g a i n s t scarlet f e v e r m a y v e r y well develop s u b s e q u e n t septic t h r o a t s d u e to t h e scarlet fever o r g a n i s m s . W e m u s t u n d e r s t a n d t h a t w h a t we g e t w h e ~ we i n j e c t five doses in t h e active i m m u n i z a t i o n p r o g r a m is p r o t e c t i o n only f r o m t h e s u b s e q u e n t f o r m a t i o n of a r a s h in case t h e i n d i v i d u a l gets i n f e c t e d w i t h one of t h e o r g a n i s m s t h a t causes t h e disease. DI-r If. L. D W Y E R , KANSAS CITY, MISSOURI.--I w o n d e r if on a c c o u n t of t h e reaction~ t h e f o u r t h or f i f t h doses m i g h t n o t be split. M o s t of m y r e a c t i o n s occurred a b o u t t h e f o u r t h a n d f i f t h dose. I f we could cut these down~ i t m i g h t be t h a t t h e n u m b e r a n d severity of r e a c t i o n s m i g h t b e decreased. DR. S I L V E R M A N . - - T h e n u m b e r a n d t y p e oe r e a c t i o n s m i g h t b e d e c r e a s e d b u t t h e n u m b e r of i ~ j e c t i o n s would be i n c r e a s e d f r o m five to seven or ten. I t would n o t b e a n e a s y p r o b l e m to se]] such a p r o g r m n to t h e public. Dt~. :FI~ANK L E E C H , WASHINGTON,D. C.--My clinical experience w i t h inoculat i o n of n u r s e s i n our h o s p i t a l a t W a s l i i n g t o n h a s b e e n equally a s good as Dr. T o o m e y ' s a t Cleveland. M y r e s u l t s have b e e n as f o r t u n a t e as his since we have definitely c u t d o w n t h e n u m b e r of scarlet f e v e r cases t h a t have occurred in our
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n u r s i n g group. We, as did the speaker, experienced frequent reactions among the nurses, but I feel t h a t it is a good measure to give to people who are intimately exposed to the disease. So far, I have had no case of scarlet fever occur among the inoculated internes and nurses. Though I feel it is a good nleasure in hospital work~ I doubt its value as a public health measure. D/~. L. F. ]3ENDER, ~tIIL~kDELPHIA,P A . - - W e have been told that there arc no reactions in children following injection of this m~teria], but I have had severe reactions in m y own f a m i l y a f t e r active immunization injections. I f other children have as severe reactions as m y own, I would hesitate to utilize active immunization indiscriminately. D/~. S H A W . - - I do not believe t h a t in the attack of the scarlet fever problem, Dick testing, active i m m u n i z a t i o n with toxin or toxoid, passive protection with scarlet fever antitoxin, or the t r e a t m e n t of scarlet fever by application of antitoxin, one dares to carry too f a r the analogy between scarlet fever and diphtheria. All of these control measures are designed with respect to the rash producing toxin as though its action were exactly comparable to the soluble toxin of diphtheria. Such a conception completely ignores the invasive and highly pathogenic properties of the streptococcus of scarlet fever which are apart f r o m its production of soluble ,toxin and which are u t t e r l y unlike the almost purely saprophytic n a t u r e of the diphtheria bacillus. W h a t e v e r is to be accomplished in scarlet fever, prevention and t r e a t m e n t is to be accomplished only by direct observation of these therapeutic agents and not by analogy to diphtheria. This is particularly t r u e in public health work. To proceed with a campaign of scarlet fever i m m u n i z a t i o n on the basis of our pl-esent knowledge, advising it to the public because of the success encountered in diphtheria immunization, m i g h t easily lead to results which would discredit not only scarlet fever immunization b u t diphtheria immunization as well. DR. W A L L - - A f t e r a p a t i e n t becomes Dick negative after active immunization, how long can we say t h a t the i m m u n i t y lasts'? DR. D W Y E R . - - I f all we get by active immunization is protection against the rash, then there would be no sense in injecting susceptible individuals a n d advocati n g active immunization. DR. G. ]3. M c F A R L A N D , DALLAS~ TEXAS.--Is it not possible t h a t due to active immunization people m i g h t contract a disease of bacterial f o r m without a rash? This would tend to increase the instance of scarlet fever and break down the efficacy of quarantine laws. I n other words, arc the benefits obtained front active immunization worth while? DI~. TOO~VIEY.--Though we m a y admit some of Dr. S h a w ' s objections, nevertheless, we cannot shut our eyes to the striking results obtained by active immunization. This has been the experience of Dr. Leech here and others who have reported in the literature. For a hospital such a protection is worth while even t h o u g h the injected individuals get reactions. The number of doses and the reactions accompanying the same are such t h a t the p r o g r a m will never become generally popular. We cannot b u t feel, however, t h a t from a clinical standpoint the patient, while perhaps still susceptible to the streptococcus causing the disease and perhaps only protected a g a i n s t the r a s h of the disease by the process of active immunization would probably be better off if he merely contracted a strreptococcie sore throat t h a n he would be if he had a streptococcus sore throat and a rash as m i g h t be the case i f he h a d not h a d active immunization. DI~. E A B L E . - - I still think t h a t active immunization is of value in private homes as among nurses in institutions. We have found t h a t over 75 per cent of our .patients were still negative two and a half years after the last active immunization
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inoculation. P e r h a p s m a n y of the reactions t h a t occur with active immunization m i g h t be due to the additional allergic f a c t o r recently described by Ando and his associates. I have been u s i n g a toxoid p r e p a r a t i o n since J a n u a r y 1st and find t h a t we do not get the terrific reactions with this material, b u t I ]Lave no definite figures to r e p o r t as yet. DR. T O O M E Y . - - W e ]lave not had a g r e a t deal of experience w i t h toxoid alt h o u g h we have injected L a r s o n ' s sodium rieinoleated m a t e r i a l in some of our n u r s i n g groups. We discontinued it when we found t h a t in some instances even a f t e r 15 injections, the n u r s e s still had positive Dick tests. We have had no experience with the new toxoid m a t e r i a l described by Dr. Earle. DR. E A R L E . - - I n our i n s t i t u t i o n a l work, we have cared f o r over 11,000 children. We have had no epidemics of scarlet fever since we s t a r t e d immunization. 33. Passive Im~,.unizatlo~.--The reports f r o m the l i t e r a t u r e as to the prophylactic value of scarlet fever a n t i t o x i n v a r y widely. Because of the complexities of individual immunity, the epidemic character of the disease, the variability of the sera, differences of virulency in organisms and the lowness of the contagious index, it is almost impossible f o r us to s ~ how any comparisons can be made f r o m which definite conclusions can be drawn. There arc, however, ~nany articles in the literature by a u t h o r s who think t h a t they have seen definite evidences of value in these p r o p h y l a c t i c injections, b u t the conclusions of most of these men were based on experiences w i t h ~nstitutional cases. I n j e c t i o n s were given as epidemics broke out and the claim is made t h a t epidemics were thus controlled. The variability of contagiousness in o r p h a n a s y h m s or institutions is so app a r e n t to any one in medical charge of such i n s t i t u t i o n s tlmt one m a y assume th'~t a n y conclusions based on possible case spread in these places arc worthless. I n the experience of one of us in one institution, one case has occurred one year with no subsequent infections and the very next year~ 17 cases followed the first case of the season. Because so few people c o n t r a c t scarlet fever a n y w a y unless directly and intinlately exposed, because even then the contagious index is low, because of the fact t h a t the therapeutic sera sensitize to horse sermn and finally because we do not feel t h a t there has been sufficient d a t a of a conclusive n a t u r e to prove t h a t there is protection established b y the injection of scarlet fever antitoxin, we feel t h a t the prophylactic use of scarlet fever a n t i t o x i n is not to be recommended. I f passive immunization has to be employed, we feel it should be w i t h convalescent scarlet fever serun].
9C. Conclusion.--Wc think t h a t active i m m u n i z a t i o n is a valuable procedure but is limited in its general application because of the m a r k e d u n t o w a r d s y m p t o m s that accompany the procedure. Because of this, we feel t h a t it should be used only to hnmunizo individuals who are intimately exposed to the disease. We believe t h a t passive i m m u n i z a t i o n with the use of scarlet fever a n t i t o x i n s in susceptiblcs is a procedure not yet justified either f r o m the evidence in the ]iteras or f r o m our own experience and finally it is not justified since it m a y sensitize individuals to horse serum.
III. Treatment A. Thera pe~tie Use of Searlet Eever A~t~toxins.--On another occasion, one of us ~ reviewed over 125 references on this subject. I n this review, it is stated t h a t the contributions in the literature could be divided into f o u r classes. *Toomey. John A. : T r e a t m e n t and Prevention of Scarlet Fever by Specific Antitoxins and Serums, J. A. ]YL A. 91: 1599. 1928.
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1. Original articles d e s c r i b i n g cases t r e a t e d b y a n t i t o x i n s in g r e a t detail with r e s u l t s a n d proper controls. 2. C u m u l a t i v e articles w i t h o u t details which merely d r a w g e n e r a l conclusions a n d which are impossible to analyze. 3. Articles whose a u t h o r s used their control eases f r o m other epidemics p a t i e n t s t r e a t e d w i t h convalescent scarlet f e v e r s e r u m or other t h e r a p y . 4. Articles whose a u t h o r s do n o t have controls.
or
A t t h a t time, r e p o r t s of t r e a t m e n t to 4,611 p a t i e n t s h a d a p p e a r e d in t h e literature. T h e a u t h o r s who f a v o r e d t h e u s e o f scarlet f e v e r a n t i t o x i n s t a t e d t h a t t h e r a s h d i s a p p e a r e d earlier, t h e t e m p e r a t u r e came down m o r e quickly, t h e p a t i e n t w a s less toxic, g o t b e t t e r sooner, a n d t h e r a t e of c o m p l i c a t i o n s w a s lessened. Some a u t h o r s h a v e said t h a t t h e d e a t h r a t e was lowered. One m a y easily dispose of such claims since it would be inconceivable h o w a n y t h e r a p y would lower t h e d e a t h r a t e a n y f u r t h e r t h a n we now experience. Curiously, the d e a t h rate of m o s t m e t r o p o l i t a n c e n t e r s h a v e been less t h a n t h e rate quoted b y one a u t h o r who claims t h a t his m o r t a l i t y w a s decreased. W e c a n n o t see how, in t h e l i g h t of vital s t a t i s t i c records, a n y one c a n seriously t h i n k t h a t t h e m o r t a l i t y r a t e h a s been in a n y w a y affected. A s f a r as t h e d i s a p p e a r a n c e of the r a s h is concerned, we c a n only s t a t e t h a t the evidence o b t a i n e d either f r o m t h e l i t e r a t u r e or f r o m our experience is not conclusive. The chief f a u l t in r e p o r t e d ' articles lies in t h e f a c t t h a t we a r e not told t h e l e n g t h o f time" t h e p a t i e n t h a d t h e r a s h b e f o r e a n t i t o x i n w a s given. U s u a l l y t h e l e n g t h of t i m e b e t w e e n a n t i t o x i n a d m i n i s t r a t i o n a n d t h e d i s a p p e a r a n c e of t h e r a s h is t h e t i m e figured. One could n o t t h e n conclude f r o m a s t u d y of t h e literature, b u t one could ~ d m i t f o r t h e sake of a r g u m e n t , t h a t t h e r a s h d i s a p p e a r s slightly m o r e quickly in t h e t r e a t e d t h a n i n t h e u n t r e a t e d case. I t is s t a t e d t h a t t h e t e m p e r a t u r e comes down m o r e quickly i f a n t i t o x i n is used. W e feel t h a t t h e m a s s of p r i n t e d evidence a n d our own experience does n o t seem to f a v o r this conclusion. S i l v e r m a n feels, however, t h a t t h e t e m p e r a t u r e m a y be lowered more quickly. A s f a r as t h e toxicity is concerned, t h e l i t e r a t u r e is n o t very definite since m o s t articles c o n t a i n no r e f e r e n c e to t h e l c n g t h of time t h e p a t i e n t s were ill before r e c e i v i n g a n t i t o x i n . N e v e r t h e l e s s , we could agree with t h e g e n e r a l conclusion t h a t t h e d u r a t i o n of toxicity is s l i g h t l y less in t h e t r e a t e d g r o u p ; b u t this difference is a n y t h i n g b u t conclusive. Some ~ u t h o r s h a v e h a d b u t few complications in t h e i r t r e a t e d seri~s in m a r k e d c o n t r a s t to i n c r e a s e s e x p e r i e n c e d in u n t r e a t e d cases. R e a d i n g the l i t e r a t u r e is c o n f u s i n g since t h e d a t a p r e s e n t o f t e n do n o t s u b s t a n t i a t e the a u t h o r s ' conclusions. I n t h e r e p o r t e d experience of one of us, t h e r e a c t u a l l y w a s a n incrcase in the complication r a t e of t h e t r e a t e d cases. T h o u g h this p o i n t h a d n o t been p r o v e d to our s a t i s f a c t i o n , we m i g h t g r a n t f o r t h e sake of a r g u m e n t t h a t t h e r e m a y be a slight decrease i a t h e complication r a t e following t h e use of a n t i t o x i n s . A r e t h e r e a n y d i s a d v a n t a g e s t h a t follow a n t i t o x i n i n j e c t i o n s ? I f so, m i g h t n o t t h e s e o u t w e i g h even t h e q u e s t i o n a b l e a d v a n t a g e s e n u m e r a t e d above? I t is common opinion a n d it is our experience tikcwise t h a t t h e r e are more r e a c t i o n s a f t e r t h e i n j e c t i o n of scarlet f e v e r a n t i t o x i n t h a n t h e r e a r e a f t e r i n j e c t i o n s of a n y other t y p e of serum. J u s t w h y t h i s is so, we do n o t know. T h e l i t e r a t u r e r e p o r t s a v e r y h i g h p e r c e n t a g e of s e r u m sickness r e a c t i o n s in w h i c h t h e p a t i e n t s h a v e h a d every t y p e o f r e s p o n s c - - c a r l y t h e r m l c , t h c r m i c w i t h u r t i c a r i a a n d edema, late u r t i c a r i a a n d a n a p h y l a e t o i d p h e n o m e n a . M o s t of t h e p a t i e n t s t r e a t e d b y u s were f a r more ill f r o m the s e r u m sickness t h a n t h e y were f r o m t h e scarlet fever.
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A d m i t t i n g all o f t h e a d v a n t a g e s v a r i o u s i n d i v i d u a l s claim, we still feel t h a t t h e r e is no r e a s o n f o r i n j e c t i n g every p a t i e n t w i t h serum. T h e evidence o b t a i n e d f r o m t h e l i t e r a t u r e does n o t w a r r a n t c o n c l u d i n g t h a t ~carlet fever a n t i t o x i n h a s proved of " i n e s t i m a b l e v a l u e " i n the t r e a t m e n t of t h i s disease a n d we would n o t r e c o m m e n d it in t h e o r d i n a r y m i l d or m o d e r a t e l y severely ill case. I f g i v e n at all, it would be only to t h e s t r i c t l y toxic p a t i e n t in t h e hope t h a t it m i g h t do some good. One of u s would even object to i t s use here since he feels t h a t convalescent scarlet f e v e r s e r u m , a h o m o l o g o u s sermn, accomplishes m o r e beneficial results. B. Coneh~iou.--F~.om a p r a c t i c a l s t a n d p o i n t , we would h e s i t a t e to r e c m n m e n d t h e use of scarlet f e v e r a n t i t o x i n s except in t h e occasional case a n d only w h e n t h e p a t i e n t h a s a s t r i c t l y toxic t y p e of t h e disease. DR. J O S E P H Y A M P O L S K Y , ATLA~T'A, GEOI~OIA.--][ would object to t h e use of scarlet fever a n t i t o x i n in p r o p h y l a x i s b e c a u s e of t h e severe r e a c t i o n s t h a t I have h a d in m y practice. T h e r e r e a c t i o n s are n o t p o r t r a y e d in t h e proper l i g h t to t h e private practitioner. T h e y a t e m u c h more severe t h a n we would s u r m i s e f r o m a c u r s o r y glance a t t h e l i t e r a t u r e . DR. S H A W . - - I would h e a r t i l y agree w i t h t h e observer a n d say t h a t if he was g o i n g to do a n y p a s s i v e i m m u n i z a t i o n , h e should u s e convalescent sermn. DR. E A R L E . - - N i g h t it n o t be a good idea i n exposed susceptiblcs to b e g i n g i v i n g skin t e s t doses of toxin, in other words, give t h e m active i m m u n i z a t i o n ? DR. T O O M E Y . - - W c feel t h a t t h e r e is no good evidence on t h i s point. One m i g h t r e a s o n t h a t a n i n d i v i d u a l who h a d been g i v e n i n j e c t i o n s in t h e i n c u b a t i o n period a n d was a b o u t to g e t t h e disease m{ght h a v e t h e disease a g g r a v a t e d . P e r s o n a l l y , we have h a d no experience a l o n g this line. DR. S I L V E R M A N . - - I aIso feel t h a t active i m m u n i z a t i o n o f exposed suseeptibles m i g h t a g g r a v a t e scarlet f e v e r i f t h e disease were to develop shortly. DR. u f o r m e r l y used scarlet f e v e r a n t i t o x i n , b u t b e c a u s e of the severe r e a c t i o n s I o b t a i n e d I n o w only use it i n selected cases a n d give it in very s m a l l doses. M y difficulty is t h e ability to d i f f e r e n t i a t e toxic eases early. I find t h a t reactions are v e r y severe i f y o u give l a r g e doses. DR. S H A W . - - I feel t h a t t h e f a l l in t e m p e r a t u r e r e a c t i o n which occur nas in such a disease as scarlet f e v e r is very a p t to be a t t r i b u t e d to t h e a n t i t o x i n . I d o u b t w h e t h e r or n o t a n t i t o x i n is of a n y value. I feel w i t h one of t h e speakers t h a t in a severe case, convalescent scarlet f e v e r s e r u m would p r o b a b l y bc of more USe. DR. J. ]~. STO~qE, ~={IOtt~LOZND,, ~II~GINIA.--~ wonder w h e n eo~valeseent scarlet f e v e r s e r u m is n o t a v a i l a b l e ' w h e t h e r t h e s e r u m of a n i n d i v i d u a l w i t h a n e g a t i v e Dick t e s t m i g h t bc utilized as a t h e r a p e u t i c agent. DR. T O O ~ I E u
do n o t k n o w of a n y articles b e n r i n g on this point.
DI~. S I L ~ E R F I A N . - - W e do n o t know the i m m u n i t y t l t e r of a p a t i e n t ' s s e r u m a n d so we c a n n o t tell t h e a n t i t o x i c v a l u e of a p a t i e n t ' s s e r u m in a q u a n t i t a t i v e way. I feel ~hat p a t i e n t s w i t h a n y h i n t of allergy should h a v e convaaescemt sermn. Dt~. E A I ~ L E . - - D o y o u h a v e to t y p e t h e blood f o r convalescent s e r u m ? DR. T O O M E Y . - - l ~ o t i f t h e blood i s to be g i v e n i n t r a m u s c u l a r l y as it u s u a l l y is or i n t r g p c r i t o n e a l l y . I f g i v e n i n t r a v e n o u s l y , t y p i n g will have to be done. DR. E A R L E . - - I gave a n t i t o x i n in c u r a t i v e doses to two children in one f a m i l y . I n one i n s t a n c e , I h a d no reaction~ good r e s u l t s a n d quick recovery. I n t h e other child, we h a d no evident results. I feel t h a t a n t i t o x i n h a s a l i m i t e d use i n some ~ases.
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DR. S I L Y E R M A N . The f a c t t h a t those individuals who get good blanching tests have good results w i t h the serum we have used makes me feel t h a t the f a u l t lies with the antitoxin. Wc use the m a t e r i a l supplied by the New York State Board of }te~lth. DR. D W Y E R . - - I feel t h a t adult Js serum is in a w a y comparable to eollvalescent s e r u m ia t h a t it has some relative value ~ud m i g h t be used. D]%. T O O M E ~ . - - W e did not use any of the New Y o r k antitox]~ ill our bl~nching tests. F r o m the published experience wltI1 men who have used their material~ t h e r e the New York State B o a r d of H e a l t h m a n u f a c t u r e s a streptococcic antitoxin.
State Board of t t e a l t h ' s Hterature a n d f r o m our is no question b u t w h a t superior b r a n d of anti-
DR. M c ~ A I g L A I ~ D . - - I wonder whether some one could tell us what the criterion in scarlet fever would be f o r diagnosis of scarlet fever in d o u b t f u l cases. Recently, we have had m a n y eases w i t h a very fine r a s h t h a t have been usually diagnosed scarlet fever. These cases had some fine peeling. DR. T O O M E u would say th'at the individuals had scarlet fever. They had a rasl b t h o u g h scanty, desquamation, t h o u g h iinc, and a sore throat, t h o u g h mild. I)]%. S T O N E . - - I wonder whether the c h a i r m a n could tell us a n y t h i n g about the n a t u r e of the r a s h a f t e r tonsillectomy. DR. T O O M E Y . - - I do n o t know the mechanism. I t m i g h t be t h a t streptococci could secondarily i n f e c t this area or the p r o t e i n a b s o r p t i o n t h a t occurs about the wound could cause this reaction. DR. E A R L E . - - D o cases ahvays have desquamation a f t e r scarlet fever? DR. S I L V E R M A N . - - I have seen m a n y f r a n k cases o f scarlet fever t h a t did not desquamate. DR. J. ]3, S T O N E , ~tlC~OND, VIR(]IN~A.--What is the significance of throag cultures in this discase~ DR. S ~ L Y E R M A N . - - I think t h a t the consensus of opinion is t h a t we cannot utilize culture methods as a means for isolation or even as a criterion of discharge f r o m this disease. (The seminar on the above points was opened with Dr. Toomey presiding. I n the absence of Dr. H o y n e of Chicago, Dr. J. ]3. Stone of I%~chmond acted as secretary.)
Academy News Dr. iRoger ~[. I)ennett of N e w York City has been a p p o i n t e d C h a i r m a n of the Committee on Nursing' E d u c a t i o n in Pediatrics to replace Dr. Ramsey who has resigned. Dr. Charles A. F i f e of Phi]adelphla has accepted a position as a member of this same committee. Dr. H e r b e r t L. Moon of Seattle has been made C h a i r m a n of the State Committee of Washington, to succeed Dr. J a y I. Durand. Dr. Stanley lqichols of A s h u r y P a r k lms succeeded Dr. J o s e p h H. Marcus as State Chairman in New Jersey.
May 13, 1932 Round TaMe Conference o~ Scarlet Fever A Practical Consideration of Skin Tests, Active and Passive Immunization and the Use of Therageutic Antitoxins Leader: John A. Toomey, M.D. ; Assistants: Archibald Hoyne, M.D., and A. Clement Silverman, M.D. I n this seminar, we are a s k e d to consider the s u b j e c t o f scarlet fever. To cover this s u b j e c t completely would t a k e more t i m e t h a n we h a v e at our disposal. Therefore, we h a v e divided it into t h r e e topics as follows: I. Skin T e s t s in Scarlet F e v e r ( I n t r o d u c e d b y Dr. S i l v e r n l a n ) - A. The Dick T e s t B. Sehu]tz C h a r l t o n Reaction O. Conehlsions I L I m m u n i z a t i o n ( I n t r o d u c e d bar Dr. T o o m e y ) - A. Active I m m u n i z a t i o n B. P a s s i v e I m m u n i z a t i o n O. Conclusions I I L T r e a t m e n t ( I n t r o d u c e d by Dr. H o y n e ) - A. The T h e r a p e u t i c U s e of Scarlet F e v e r A n t i t o x i n s B. Conclusions I. Skin Tests in Scarlet l~ever
A. The DivIc T e s t . - - F o r clarity, one need only m e n t i o n t h a t t h e Dick test is a t e s t to d e t e r m i n e t h e s u s c e p t i b i l i t y of a n individual to scarlet fever a n d t h a t its discovery by t h e Dicks h a s b e e n of exceeding i m p o r t a n c e to medicine. M o s t i n d i v i d u a l s who use this t e s t r o u t i n e l y have some d o u b t s as to i t s absolute specificity since m a n y people develop scarlet fever who have h a d n e g a t i v e Dick tests. There are likewise people who have h a d scarlet f e v e r who still h a v e positive Dick t e s t s at t h e end of t h e i r illness 30 d a y s later. I t m i g h t be said of t h e f o r m e r cases t h a t s u c h i n d i v i d u a l s have h a d a n a t u r a l loss of i m m u n i t y , as a r e s u l t of which t h e y h a d become susceptible to scarlet fever. T h a t this c a n n o t always be the case is seen f r o m t h e f a c t t h a t t h e s e p a t i e n t s still h a v e n e g a t i v e Dick t e s t s a t t h e b e g i n n i n g o f the scarlet f e v e r r a s h when, theoretically, t h e y ~hould have positive tests. The a c t u a l p e r c e n t a g e of these n e g a t i v e Dick r e a c t o r s who develop scarlet f e v e r is n o t known, b u t our ex perienee i n d i c a t e s t h a t s u c h cases a r e n o t rare.
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There is another group of scarlet fever patients who never have h a d Dick tests previous to admission to the hospital, but who show negative Dick reactions on admission a t the height of their rash and when theoretically they should have a positive Dick reaction. There are so m a n y of these cases admitted to oar hospitals t h a t the finding of a negative Dick test a t the height of a r a s h cannot be said to rule out scarlet fever. I t is very probable t h a t the r a s h in these instances is caused by ether strains t h a n those originally described as being the sole causes of the disease. Certainly, the s t r a i n t h a t causes scarlet fever one year m a y not be t h a t which causes an epidemic of the disease the succeeding year since the m a j o r i t y of patients of the first year m a y be Dick positive and the m a j o r i t y of the second, Dick negative. DR. E. B. SHAW, S - ~ FR_~NCI~CO, CALI~e~I:~.--I agree with the conclusion of Dr. Silverman a n d ~ i s h to state t h a t in m y experience there was a definite lack of correlation between the blanching findings a n d t h e Dick t e s t itself. I should like to ask whether the Dick test can be definitely stated to be a toxin reaction? The response of the skin to a Dick test is hardly t h e same as a Schick reaction. I t begins promptly and gradually reaches a m a x i m u m i n twenty-four hours. I t is not characterized by the latent period so characteristic of the tissue response to a true toxin, l%rthermore, there has not~ to m y knowledge, been shown the same degree of consistency between the Dick reaction a n d the i m m u n e state to scarlet fever t h a t one encounters with regard to the Schlck reaction and i m m u n i t y to diphtheria. I s not the Dick reaction somewhat intermediate in its n a t u r e between a toxin and a n allergic skin response? DR. J. S. W A L L , WASItING~0~, D. C . - - P e r h a p s the percentage of errors t h a t occur in interpretation e f the Dick test m a y be due to the time of reading the test. I suggest t h a t waiting a day or so more m i g h t reveal a number of delayed reactors. I feel t h a t it m i g h t be very 4iflleult to interpret Dick tests at the height of the rash. DR. A. C. SILVERlVfAN, SYRACUSe, l~aw YORK.--The Schick test differs from the Dick test in t h a t the reaction persists longer. The former material is less stable t h a n the latter. DR. C. A. E A R L E , DES P b A I ~ S , ILLINe]s.--I have given over 11,000 Dick tests during the course of m y work in several institutions. I have seen only one negative Dick reactor develop scarlet fever. All those who have had scarlet fever, in cur e~perience, have always h a d a negative Dick test. I have great confidence in the Dick test as evidence of susceptibility and i m m u n i t y to this disease. There m a y be some physical reason to explain the number of negative Dick tests t h a t occur in m a n y people who should be positive according to the history. DR. 5. A. T O O M E u CLEV~NI~, O~IO.--I think t h a t the Dicks have show~ t h a t m a n y minor apparently innocuous physical t h i n g s m a y cause destruction of the toxin. W h e n one remembers t h a t 1 c.e. of 4 day toxin m a y contain as h i g h as 6,000 or more skin test units, one can u n d e r s t a n d how easily physical reactions m i g h t destroy this minute amount of toxin. Too much alcohol, tincture of iodine, antiseptics of various kinds can vitiate the test. Great pains should be followed in the care of needles and syringes. Both should be dry sterilized, since even the small amount of moisture and water of condensatloa t h a t collects a f t e r cooling m i g h t alter the test reading. P a y i n g attention to all these points, we still have negative Dick test reactors in individuals who should be positive. We feel t h a t the belief t h a t there are only two strains of specific streptococci t h a t cause the disease entity of scarlet fever is entirely erroneous. B. ~gchvltz Charlto~ Reaction.--These authors discovered t h a t convalescent scarlet fever serum injected into the skin of an acutely ill scarlet fever p a t i e n t blanched
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the r a s h a b o u t t h e injection. T h e y concluded t h a t a specific p r o d u c t h a d a p p e a r e d in t h e s e r u m of convalescent p a t i e n t s which b r o u g h t a b o u t a local cure of the disease a n d t h a t t h e r e a c t i o n w a s specific. I t m i g h t be i n t e r e s t i n g to m e n t i o n t h a t t h e specificity a n d t h e w o r t h of a n y a n t i t o x i n is o f t e n g a u g e d b y i t s a b i l i t y to locally b l a n c h t h e r a s h of a n acutely ill s c a r l e t f e v e r p a t i e n t . I f t h i s criterion is true, t h e r e a r e m a n y a n t i t o x i n s now on t h e m a r k e t t h a t a r e w o r t h l e s s since m a n y m e r e l y cause a local i n f l a m m a t o r y reaction a n d l~o~blanching whatever. One cannot s a y t h a t a r a s h is n o t a scarlet f e v e r r a s h j u s t because scarlet f e v e r a n t i t o x i n does n o t ]oca]Iy b l a n c h t h i s rash, f o r we h a v e h a d h u n d r e d s of cases in w h i c h the" r a s h h a s n o t b e e n b l a n c h e d b y scarlet fever a n t i t o x i n a n d h a s been b y eoineidentally i n j e c t e d convalescent scarlet fever serum. T h e s e p a t i e n t s have h a d positive Schultz C h a r l t o n t e s t s with convalescent serum, a n e g a t i v e reaction with scarlet fever a n t i t o x i n s a n d , c u r i o u s l y enough, m a n y h a v e h a d a n e g a t i v e Dick t e s t a t the s a m e time. W e feel t h a t we c a n n o t be too specific a b o u t conclusionu in r e g a r d to t h e Schultz C h a r l t o n p h e n o m e n o n a n d a l t h o u g h a positive Schultz C h a r l t o n p h e n o m e n o n o b t a i n e d w i t h convalescent scarlet f e v e r s e r u m is f a i r l y conclusive, y e t i t s absence does n o t conclusively rule out t h e disease. C. Conch~sio~s.--We feel t h a t t h e Dick tes~ is a very valuable aid in d e t e c t i n g s u s c e p t i b i l i t y to scarlet fever, b u t we do n o t t h i n k t h a t it is a n absolutely p e r f e c t test. W e feel t h a t a n e g a t i v e r e a c t i o n does n o t rule o u t the p o s s i b i l i t y of scarlet fever in i n d i v i d u a l s w i t h s c a r l a t i n a l rashes. W e would say, however, t h a t the exceptions are n o t i n n u m e r a b l e a n d t h a t f o r p r a c t i c a l p u r p o s e s , one could ignore t h e m , merely k e e p i n g i n m i n d t h e l i m i t a t i o n s . A positive Sehnltz C h a r l t o n reaction is good evidence f o r the presence of scarlet fever~ b u t a n e g a t i v e Schultz C h a r l t o n does n o t rule out t h e disease. DR. W A L L - - T h e Schultz C h a r l t o n t e s t s c a n o f t e n be seen a n d a p p r e c i a t e d b e t t e r i f r e a d at a d i s t a n c e r a t h e r t h a n closely. DR. S H A W . - - T h e Schultz C h a r l t o n r e a c t i o n is of no g r e a t value. I t is no good in d o u b t f u l eases a n d c e r t a i n l y n o t needed in t y p i c a l ones. I a g r e e with t h e s p e a k e r w h e n he s t a t e s t h a t convalescent s e r u m gives b e t t e r b l a n c h i n g t h a n antitoxin. DR. T O O M E Y . - - D r . S h a w h a s raised the question of p r a c t i c a b i l i t y of t h e Schultz C h a r l t o n test. W e agree t h a t it is useless in a n y case t h a t h a s a p a p u l a t e d or s p l o t c h y m a e u l a t e d r a s h a n d these u s u a l l y are t h e very r a s h e s a b o u t which we are i n doubt. W c agree, likewise, t h a t t h e r e is .no element of d o u b t in t h e typical scarlet fever case a n d t h e b l a n c h i n g t e s t in t h o s e i n s t a n c e s would be only of a c a d e m i c interest. Dr, S i l v e r m a n s t a t e d t h a t t h e t e s t could n o t be u s e d to rule o u t scarlet f e v e r in a n i n d i v i d u a l who tins a t y p i c a l r a s h . To this we agree, f o r we h a v e seen h u n d r e d s of cases who do n o t b l a n c h w i t h t h e so-called commercial antitoxins. Some of these eases did b l a n c h w i t h convalescent serum. Incidenta]ly, it is quite definite t h a t one c a n n o t sell scarlet fever a n t i t o x i n s on t h e b a s i s of b l a n c h i n g a b i l i t y since ulost of the sera now sold have poor b l a n c h i n g qualities. I f , however, b l a n c h i n g does occur with s e r u m we do n o t see how one could ignore t h e possibilities such a r e a c t i o n indicates. II. I m m u n i z a t i o n A . A c t i v e I m m u n i z a t i o n , W i t h To,r,@, Ma,de F~'om Strep~ocovci.--AlI our practical experience h a s b e e n w i t h t h e u s e of Dick t o x i n as p u t o u t b y t h e Squibb C o m p a n y , t h e originaI licensees u n d e r t h e D i c k s ' p a t e n t . I n the q u e s t i o n of i m m u n i z a t i o n , two t h i n g s have to be considered, the r e s u l t s of i m m u n i z a t i o n a n d t h e possible d a n g e r s t h a t m i g h t occur d u r i n g its use,
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F o r t h e p a s t s e v e n or e i g h t years, one of u s (J. A. T.) h a s b e e n i m m u n i z i n g n u r s e s who e n t e r e d t h e local t r a i n i n g school a n d over 953 s t u d e n t s f o u n d to have positive Dick t e s t s h a v e been g i v e n t h e five i m m u n i z i n g i n j e c t i o n s r e c o m m e n d e d . N o t one of t h e n u r s e s h a d developed scarlet fever. Several e n t r a n t s incompletely i m m u n i z e d have developed t h e disease. T h e Dick test b e c a m e n e g a t i v e in t h e i m m u n i z e d i n d i v i d u a l 10 d a y s to 2 ~m o n t h s a f t e r the l a s t injection. S i m i l a r experiences a r e n o t e d in the literature. Likewise, wo have i n j e c t e d m a n y children with similar results. A r e t h e r e a n y d i s a d v a n t a g e s i n this p r o g r a m ? W e h a v e f o u n d some i n d i v i d u a l s so sensitive to t h e m a t e r i a l t h a t i m m u n i z a t i o n h a d to be d i s c o n t i n u e d a f t e r t h e first or second injection. R e a c t i o n s do occur with i m m u n i z a t i o n p r o g r a m s . A s a m a t t e r of fact~ we h a v e h a d b u t f e w n u r s e s who h a v e n o t h a d some reactions, t h e m i l d e s t of w h i c h were~ local i n f l a m m a t o r y r e s p o n s e s in 70 to 80 per c e n t of t h e g r o u p i m m u n i z e d . A p p r o x i m a t e l y l 0 to 15 per c e n t of t h e s e i n d i v i d u a l s were sick e n o u g h to be confined to b e d f r o m one to t h r e e days. B e c a u s e of t h e s e reactions, we do n o t believe t h a t t h e a d u l t s should ever b e inj e c t e d w i t h o u t a n initial d e t e r m i n a t i o n of t h e i r s e n s i t i v i t y ; i.e., unless t h e y have a positive Dick t e s t . Some s a y t h a t a d u l t s m a y have reactions b u t t h a t children do not, a n d t h a t , therefore, i n j e c t i o n s should be m a d e early, possibly b e t w e e n 2 a n d 5 y e a r s of age arLd m a d e w i t h o u t even d o i n g a Dick test. W e c a n n o t a g r e e with t h e s e e m i n g l y g e n e r a l opinion t h a t children do n o t h a v e r e a c t i o n s since we have h a d local a n d g e n e r a l r e a c t i o n s quite as severe as those seen in a d u l t s ; therefor% we feel t h a t children too, s h o u l d h a v e a d e t e r m i n a t i o n of s u s c e p t i b i l i t y before i n j e c t i o n s are
given. The local r e a c t i o n s r e f e r r e d to. m a y be a n y t h i n g f r o m a simple well d e m a r c a t e d lesion to a n a n g r y i n f l a m m a t o r y response t h a t involves t h e whole arm. T h e g e n e r a l r e a e t i o n s a r e t h o s e t h a t occur w i t h clinical a t t a c k s of scarlet fevei b i.e., vomitlng~ severe p r o s t r a t i o n , h i g h t e m p e r a t u r e , a r t h r i t i s , adenitis, a n d o f t e n enough~ a rash. B e c a u s e of t h e s e reactions, we ~eel t h a t the. m e t h o d should be utilized to. imm u n i z e a ~ i v e l y only t h o s e i n d i v i d u a l s who m a y experience m a s s i v e exposure in t h e i r work; i.e., n u r s e s a n d doctors w o r k i n g i n c o n t a g i o u s h o s p i t a l s or children in i n s t i t u t i o n s . W e do n o t feel t h a t t h e p r o c e d u r e should be a d o p t e d as ~ public h e a l t h m e a s u r e since f u r t h e r work will have to b e done to create a m o r e i n n o c u o u s product. One m u s t r e m e m b e r also t h a t active i m m u n i z a t i o n does n o t necessarily give b a c t e r i a l i m m u n i t y , so t h a t a person w h o either h a s h a d scarlet f e v e r or h a s bee~l actively i m m u n i z e d a g a i n s t scarlet f e v e r m a y v e r y well develop s u b s e q u e n t septic t h r o a t s d u e to t h e scarlet fever o r g a n i s m s . W e m u s t u n d e r s t a n d t h a t w h a t we g e t w h e ~ we i n j e c t five doses in t h e active i m m u n i z a t i o n p r o g r a m is p r o t e c t i o n only f r o m t h e s u b s e q u e n t f o r m a t i o n of a r a s h in case t h e i n d i v i d u a l gets i n f e c t e d w i t h one of t h e o r g a n i s m s t h a t causes t h e disease. DI-r If. L. D W Y E R , KANSAS CITY, MISSOURI.--I w o n d e r if on a c c o u n t of t h e reaction~ t h e f o u r t h or f i f t h doses m i g h t n o t be split. M o s t of m y r e a c t i o n s occurred a b o u t t h e f o u r t h a n d f i f t h dose. I f we could cut these down~ i t m i g h t be t h a t t h e n u m b e r a n d severity of r e a c t i o n s m i g h t b e decreased. DR. S I L V E R M A N . - - T h e n u m b e r a n d t y p e oe r e a c t i o n s m i g h t b e d e c r e a s e d b u t t h e n u m b e r of i ~ j e c t i o n s would be i n c r e a s e d f r o m five to seven or ten. I t would n o t b e a n e a s y p r o b l e m to se]] such a p r o g r m n to t h e public. Dt~. :FI~ANK L E E C H , WASHINGTON,D. C.--My clinical experience w i t h inoculat i o n of n u r s e s i n our h o s p i t a l a t W a s l i i n g t o n h a s b e e n equally a s good as Dr. T o o m e y ' s a t Cleveland. M y r e s u l t s have b e e n as f o r t u n a t e as his since we have definitely c u t d o w n t h e n u m b e r of scarlet f e v e r cases t h a t have occurred in our
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n u r s i n g group. We, as did the speaker, experienced frequent reactions among the nurses, but I feel t h a t it is a good measure to give to people who are intimately exposed to the disease. So far, I have had no case of scarlet fever occur among the inoculated internes and nurses. Though I feel it is a good nleasure in hospital work~ I doubt its value as a public health measure. D/~. L. F. ]3ENDER, ~tIIL~kDELPHIA,P A . - - W e have been told that there arc no reactions in children following injection of this m~teria], but I have had severe reactions in m y own f a m i l y a f t e r active immunization injections. I f other children have as severe reactions as m y own, I would hesitate to utilize active immunization indiscriminately. D/~. S H A W . - - I do not believe t h a t in the attack of the scarlet fever problem, Dick testing, active i m m u n i z a t i o n with toxin or toxoid, passive protection with scarlet fever antitoxin, or the t r e a t m e n t of scarlet fever by application of antitoxin, one dares to carry too f a r the analogy between scarlet fever and diphtheria. All of these control measures are designed with respect to the rash producing toxin as though its action were exactly comparable to the soluble toxin of diphtheria. Such a conception completely ignores the invasive and highly pathogenic properties of the streptococcus of scarlet fever which are apart f r o m its production of soluble ,toxin and which are u t t e r l y unlike the almost purely saprophytic n a t u r e of the diphtheria bacillus. W h a t e v e r is to be accomplished in scarlet fever, prevention and t r e a t m e n t is to be accomplished only by direct observation of these therapeutic agents and not by analogy to diphtheria. This is particularly t r u e in public health work. To proceed with a campaign of scarlet fever i m m u n i z a t i o n on the basis of our pl-esent knowledge, advising it to the public because of the success encountered in diphtheria immunization, m i g h t easily lead to results which would discredit not only scarlet fever immunization b u t diphtheria immunization as well. DR. W A L L - - A f t e r a p a t i e n t becomes Dick negative after active immunization, how long can we say t h a t the i m m u n i t y lasts'? DR. D W Y E R . - - I f all we get by active immunization is protection against the rash, then there would be no sense in injecting susceptible individuals a n d advocati n g active immunization. DR. G. ]3. M c F A R L A N D , DALLAS~ TEXAS.--Is it not possible t h a t due to active immunization people m i g h t contract a disease of bacterial f o r m without a rash? This would tend to increase the instance of scarlet fever and break down the efficacy of quarantine laws. I n other words, arc the benefits obtained front active immunization worth while? DI~. TOO~VIEY.--Though we m a y admit some of Dr. S h a w ' s objections, nevertheless, we cannot shut our eyes to the striking results obtained by active immunization. This has been the experience of Dr. Leech here and others who have reported in the literature. For a hospital such a protection is worth while even t h o u g h the injected individuals get reactions. The number of doses and the reactions accompanying the same are such t h a t the p r o g r a m will never become generally popular. We cannot b u t feel, however, t h a t from a clinical standpoint the patient, while perhaps still susceptible to the streptococcus causing the disease and perhaps only protected a g a i n s t the r a s h of the disease by the process of active immunization would probably be better off if he merely contracted a strreptococcie sore throat t h a n he would be if he had a streptococcus sore throat and a rash as m i g h t be the case i f he h a d not h a d active immunization. DI~. E A B L E . - - I still think t h a t active immunization is of value in private homes as among nurses in institutions. We have found t h a t over 75 per cent of our .patients were still negative two and a half years after the last active immunization
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inoculation. P e r h a p s m a n y of the reactions t h a t occur with active immunization m i g h t be due to the additional allergic f a c t o r recently described by Ando and his associates. I have been u s i n g a toxoid p r e p a r a t i o n since J a n u a r y 1st and find t h a t we do not get the terrific reactions with this material, b u t I ]Lave no definite figures to r e p o r t as yet. DR. T O O M E Y . - - W e ]lave not had a g r e a t deal of experience w i t h toxoid alt h o u g h we have injected L a r s o n ' s sodium rieinoleated m a t e r i a l in some of our n u r s i n g groups. We discontinued it when we found t h a t in some instances even a f t e r 15 injections, the n u r s e s still had positive Dick tests. We have had no experience with the new toxoid m a t e r i a l described by Dr. Earle. DR. E A R L E . - - I n our i n s t i t u t i o n a l work, we have cared f o r over 11,000 children. We have had no epidemics of scarlet fever since we s t a r t e d immunization. 33. Passive Im~,.unizatlo~.--The reports f r o m the l i t e r a t u r e as to the prophylactic value of scarlet fever a n t i t o x i n v a r y widely. Because of the complexities of individual immunity, the epidemic character of the disease, the variability of the sera, differences of virulency in organisms and the lowness of the contagious index, it is almost impossible f o r us to s ~ how any comparisons can be made f r o m which definite conclusions can be drawn. There arc, however, ~nany articles in the literature by a u t h o r s who think t h a t they have seen definite evidences of value in these p r o p h y l a c t i c injections, b u t the conclusions of most of these men were based on experiences w i t h ~nstitutional cases. I n j e c t i o n s were given as epidemics broke out and the claim is made t h a t epidemics were thus controlled. The variability of contagiousness in o r p h a n a s y h m s or institutions is so app a r e n t to any one in medical charge of such i n s t i t u t i o n s tlmt one m a y assume th'~t a n y conclusions based on possible case spread in these places arc worthless. I n the experience of one of us in one institution, one case has occurred one year with no subsequent infections and the very next year~ 17 cases followed the first case of the season. Because so few people c o n t r a c t scarlet fever a n y w a y unless directly and intinlately exposed, because even then the contagious index is low, because of the fact t h a t the therapeutic sera sensitize to horse sermn and finally because we do not feel t h a t there has been sufficient d a t a of a conclusive n a t u r e to prove t h a t there is protection established b y the injection of scarlet fever antitoxin, we feel t h a t the prophylactic use of scarlet fever a n t i t o x i n is not to be recommended. I f passive immunization has to be employed, we feel it should be w i t h convalescent scarlet fever serun].
9C. Conclusion.--Wc think t h a t active i m m u n i z a t i o n is a valuable procedure but is limited in its general application because of the m a r k e d u n t o w a r d s y m p t o m s that accompany the procedure. Because of this, we feel t h a t it should be used only to hnmunizo individuals who are intimately exposed to the disease. We believe t h a t passive i m m u n i z a t i o n with the use of scarlet fever a n t i t o x i n s in susceptiblcs is a procedure not yet justified either f r o m the evidence in the ]iteras or f r o m our own experience and finally it is not justified since it m a y sensitize individuals to horse serum.
III. Treatment A. Thera pe~tie Use of Searlet Eever A~t~toxins.--On another occasion, one of us ~ reviewed over 125 references on this subject. I n this review, it is stated t h a t the contributions in the literature could be divided into f o u r classes. *Toomey. John A. : T r e a t m e n t and Prevention of Scarlet Fever by Specific Antitoxins and Serums, J. A. ]YL A. 91: 1599. 1928.
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1. Original articles d e s c r i b i n g cases t r e a t e d b y a n t i t o x i n s in g r e a t detail with r e s u l t s a n d proper controls. 2. C u m u l a t i v e articles w i t h o u t details which merely d r a w g e n e r a l conclusions a n d which are impossible to analyze. 3. Articles whose a u t h o r s used their control eases f r o m other epidemics p a t i e n t s t r e a t e d w i t h convalescent scarlet f e v e r s e r u m or other t h e r a p y . 4. Articles whose a u t h o r s do n o t have controls.
or
A t t h a t time, r e p o r t s of t r e a t m e n t to 4,611 p a t i e n t s h a d a p p e a r e d in t h e literature. T h e a u t h o r s who f a v o r e d t h e u s e o f scarlet f e v e r a n t i t o x i n s t a t e d t h a t t h e r a s h d i s a p p e a r e d earlier, t h e t e m p e r a t u r e came down m o r e quickly, t h e p a t i e n t w a s less toxic, g o t b e t t e r sooner, a n d t h e r a t e of c o m p l i c a t i o n s w a s lessened. Some a u t h o r s h a v e said t h a t t h e d e a t h r a t e was lowered. One m a y easily dispose of such claims since it would be inconceivable h o w a n y t h e r a p y would lower t h e d e a t h r a t e a n y f u r t h e r t h a n we now experience. Curiously, the d e a t h rate of m o s t m e t r o p o l i t a n c e n t e r s h a v e been less t h a n t h e rate quoted b y one a u t h o r who claims t h a t his m o r t a l i t y w a s decreased. W e c a n n o t see how, in t h e l i g h t of vital s t a t i s t i c records, a n y one c a n seriously t h i n k t h a t t h e m o r t a l i t y r a t e h a s been in a n y w a y affected. A s f a r as t h e d i s a p p e a r a n c e of the r a s h is concerned, we c a n only s t a t e t h a t the evidence o b t a i n e d either f r o m t h e l i t e r a t u r e or f r o m our experience is not conclusive. The chief f a u l t in r e p o r t e d ' articles lies in t h e f a c t t h a t we a r e not told t h e l e n g t h o f time" t h e p a t i e n t h a d t h e r a s h b e f o r e a n t i t o x i n w a s given. U s u a l l y t h e l e n g t h of t i m e b e t w e e n a n t i t o x i n a d m i n i s t r a t i o n a n d t h e d i s a p p e a r a n c e of t h e r a s h is t h e t i m e figured. One could n o t t h e n conclude f r o m a s t u d y of t h e literature, b u t one could ~ d m i t f o r t h e sake of a r g u m e n t , t h a t t h e r a s h d i s a p p e a r s slightly m o r e quickly in t h e t r e a t e d t h a n i n t h e u n t r e a t e d case. I t is s t a t e d t h a t t h e t e m p e r a t u r e comes down m o r e quickly i f a n t i t o x i n is used. W e feel t h a t t h e m a s s of p r i n t e d evidence a n d our own experience does n o t seem to f a v o r this conclusion. S i l v e r m a n feels, however, t h a t t h e t e m p e r a t u r e m a y be lowered more quickly. A s f a r as t h e toxicity is concerned, t h e l i t e r a t u r e is n o t very definite since m o s t articles c o n t a i n no r e f e r e n c e to t h e l c n g t h of time t h e p a t i e n t s were ill before r e c e i v i n g a n t i t o x i n . N e v e r t h e l e s s , we could agree with t h e g e n e r a l conclusion t h a t t h e d u r a t i o n of toxicity is s l i g h t l y less in t h e t r e a t e d g r o u p ; b u t this difference is a n y t h i n g b u t conclusive. Some ~ u t h o r s h a v e h a d b u t few complications in t h e i r t r e a t e d seri~s in m a r k e d c o n t r a s t to i n c r e a s e s e x p e r i e n c e d in u n t r e a t e d cases. R e a d i n g the l i t e r a t u r e is c o n f u s i n g since t h e d a t a p r e s e n t o f t e n do n o t s u b s t a n t i a t e the a u t h o r s ' conclusions. I n t h e r e p o r t e d experience of one of us, t h e r e a c t u a l l y w a s a n incrcase in the complication r a t e of t h e t r e a t e d cases. T h o u g h this p o i n t h a d n o t been p r o v e d to our s a t i s f a c t i o n , we m i g h t g r a n t f o r t h e sake of a r g u m e n t t h a t t h e r e m a y be a slight decrease i a t h e complication r a t e following t h e use of a n t i t o x i n s . A r e t h e r e a n y d i s a d v a n t a g e s t h a t follow a n t i t o x i n i n j e c t i o n s ? I f so, m i g h t n o t t h e s e o u t w e i g h even t h e q u e s t i o n a b l e a d v a n t a g e s e n u m e r a t e d above? I t is common opinion a n d it is our experience tikcwise t h a t t h e r e are more r e a c t i o n s a f t e r t h e i n j e c t i o n of scarlet f e v e r a n t i t o x i n t h a n t h e r e a r e a f t e r i n j e c t i o n s of a n y other t y p e of serum. J u s t w h y t h i s is so, we do n o t know. T h e l i t e r a t u r e r e p o r t s a v e r y h i g h p e r c e n t a g e of s e r u m sickness r e a c t i o n s in w h i c h t h e p a t i e n t s h a v e h a d every t y p e o f r e s p o n s c - - c a r l y t h e r m l c , t h c r m i c w i t h u r t i c a r i a a n d edema, late u r t i c a r i a a n d a n a p h y l a e t o i d p h e n o m e n a . M o s t of t h e p a t i e n t s t r e a t e d b y u s were f a r more ill f r o m the s e r u m sickness t h a n t h e y were f r o m t h e scarlet fever.
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A d m i t t i n g all o f t h e a d v a n t a g e s v a r i o u s i n d i v i d u a l s claim, we still feel t h a t t h e r e is no r e a s o n f o r i n j e c t i n g every p a t i e n t w i t h serum. T h e evidence o b t a i n e d f r o m t h e l i t e r a t u r e does n o t w a r r a n t c o n c l u d i n g t h a t ~carlet fever a n t i t o x i n h a s proved of " i n e s t i m a b l e v a l u e " i n the t r e a t m e n t of t h i s disease a n d we would n o t r e c o m m e n d it in t h e o r d i n a r y m i l d or m o d e r a t e l y severely ill case. I f g i v e n at all, it would be only to t h e s t r i c t l y toxic p a t i e n t in t h e hope t h a t it m i g h t do some good. One of u s would even object to i t s use here since he feels t h a t convalescent scarlet f e v e r s e r u m , a h o m o l o g o u s sermn, accomplishes m o r e beneficial results. B. Coneh~iou.--F~.om a p r a c t i c a l s t a n d p o i n t , we would h e s i t a t e to r e c m n m e n d t h e use of scarlet f e v e r a n t i t o x i n s except in t h e occasional case a n d only w h e n t h e p a t i e n t h a s a s t r i c t l y toxic t y p e of t h e disease. DR. J O S E P H Y A M P O L S K Y , ATLA~T'A, GEOI~OIA.--][ would object to t h e use of scarlet fever a n t i t o x i n in p r o p h y l a x i s b e c a u s e of t h e severe r e a c t i o n s t h a t I have h a d in m y practice. T h e r e r e a c t i o n s are n o t p o r t r a y e d in t h e proper l i g h t to t h e private practitioner. T h e y a t e m u c h more severe t h a n we would s u r m i s e f r o m a c u r s o r y glance a t t h e l i t e r a t u r e . DR. S H A W . - - I would h e a r t i l y agree w i t h t h e observer a n d say t h a t if he was g o i n g to do a n y p a s s i v e i m m u n i z a t i o n , h e should u s e convalescent sermn. DR. E A R L E . - - N i g h t it n o t be a good idea i n exposed susceptiblcs to b e g i n g i v i n g skin t e s t doses of toxin, in other words, give t h e m active i m m u n i z a t i o n ? DR. T O O M E Y . - - W c feel t h a t t h e r e is no good evidence on t h i s point. One m i g h t r e a s o n t h a t a n i n d i v i d u a l who h a d been g i v e n i n j e c t i o n s in t h e i n c u b a t i o n period a n d was a b o u t to g e t t h e disease m{ght h a v e t h e disease a g g r a v a t e d . P e r s o n a l l y , we have h a d no experience a l o n g this line. DR. S I L V E R M A N . - - I aIso feel t h a t active i m m u n i z a t i o n o f exposed suseeptibles m i g h t a g g r a v a t e scarlet f e v e r i f t h e disease were to develop shortly. DR. u f o r m e r l y used scarlet f e v e r a n t i t o x i n , b u t b e c a u s e of the severe r e a c t i o n s I o b t a i n e d I n o w only use it i n selected cases a n d give it in very s m a l l doses. M y difficulty is t h e ability to d i f f e r e n t i a t e toxic eases early. I find t h a t reactions are v e r y severe i f y o u give l a r g e doses. DR. S H A W . - - I feel t h a t t h e f a l l in t e m p e r a t u r e r e a c t i o n which occur nas in such a disease as scarlet f e v e r is very a p t to be a t t r i b u t e d to t h e a n t i t o x i n . I d o u b t w h e t h e r or n o t a n t i t o x i n is of a n y value. I feel w i t h one of t h e speakers t h a t in a severe case, convalescent scarlet f e v e r s e r u m would p r o b a b l y bc of more USe. DR. J. ]~. STO~qE, ~={IOtt~LOZND,, ~II~GINIA.--~ wonder w h e n eo~valeseent scarlet f e v e r s e r u m is n o t a v a i l a b l e ' w h e t h e r t h e s e r u m of a n i n d i v i d u a l w i t h a n e g a t i v e Dick t e s t m i g h t bc utilized as a t h e r a p e u t i c agent. DR. T O O ~ I E u
do n o t k n o w of a n y articles b e n r i n g on this point.
DI~. S I L ~ E R F I A N . - - W e do n o t know the i m m u n i t y t l t e r of a p a t i e n t ' s s e r u m a n d so we c a n n o t tell t h e a n t i t o x i c v a l u e of a p a t i e n t ' s s e r u m in a q u a n t i t a t i v e way. I feel ~hat p a t i e n t s w i t h a n y h i n t of allergy should h a v e convaaescemt sermn. Dt~. E A I ~ L E . - - D o y o u h a v e to t y p e t h e blood f o r convalescent s e r u m ? DR. T O O M E Y . - - l ~ o t i f t h e blood i s to be g i v e n i n t r a m u s c u l a r l y as it u s u a l l y is or i n t r g p c r i t o n e a l l y . I f g i v e n i n t r a v e n o u s l y , t y p i n g will have to be done. DR. E A R L E . - - I gave a n t i t o x i n in c u r a t i v e doses to two children in one f a m i l y . I n one i n s t a n c e , I h a d no reaction~ good r e s u l t s a n d quick recovery. I n t h e other child, we h a d no evident results. I feel t h a t a n t i t o x i n h a s a l i m i t e d use i n some ~ases.
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DR. S I L Y E R M A N . The f a c t t h a t those individuals who get good blanching tests have good results w i t h the serum we have used makes me feel t h a t the f a u l t lies with the antitoxin. Wc use the m a t e r i a l supplied by the New York State Board of }te~lth. DR. D W Y E R . - - I feel t h a t adult Js serum is in a w a y comparable to eollvalescent s e r u m ia t h a t it has some relative value ~ud m i g h t be used. D]%. T O O M E ~ . - - W e did not use any of the New Y o r k antitox]~ ill our bl~nching tests. F r o m the published experience wltI1 men who have used their material~ t h e r e the New York State B o a r d of H e a l t h m a n u f a c t u r e s a streptococcic antitoxin.
State Board of t t e a l t h ' s Hterature a n d f r o m our is no question b u t w h a t superior b r a n d of anti-
DR. M c ~ A I g L A I ~ D . - - I wonder whether some one could tell us what the criterion in scarlet fever would be f o r diagnosis of scarlet fever in d o u b t f u l cases. Recently, we have had m a n y eases w i t h a very fine r a s h t h a t have been usually diagnosed scarlet fever. These cases had some fine peeling. DR. T O O M E u would say th'at the individuals had scarlet fever. They had a rasl b t h o u g h scanty, desquamation, t h o u g h iinc, and a sore throat, t h o u g h mild. I)]%. S T O N E . - - I wonder whether the c h a i r m a n could tell us a n y t h i n g about the n a t u r e of the r a s h a f t e r tonsillectomy. DR. T O O M E Y . - - I do n o t know the mechanism. I t m i g h t be t h a t streptococci could secondarily i n f e c t this area or the p r o t e i n a b s o r p t i o n t h a t occurs about the wound could cause this reaction. DR. E A R L E . - - D o cases ahvays have desquamation a f t e r scarlet fever? DR. S I L V E R M A N . - - I have seen m a n y f r a n k cases o f scarlet fever t h a t did not desquamate. DR. J. ]3, S T O N E , ~tlC~OND, VIR(]IN~A.--What is the significance of throag cultures in this discase~ DR. S ~ L Y E R M A N . - - I think t h a t the consensus of opinion is t h a t we cannot utilize culture methods as a means for isolation or even as a criterion of discharge f r o m this disease. (The seminar on the above points was opened with Dr. Toomey presiding. I n the absence of Dr. H o y n e of Chicago, Dr. J. ]3. Stone of I%~chmond acted as secretary.)
Academy News Dr. iRoger ~[. I)ennett of N e w York City has been a p p o i n t e d C h a i r m a n of the Committee on Nursing' E d u c a t i o n in Pediatrics to replace Dr. Ramsey who has resigned. Dr. Charles A. F i f e of Phi]adelphla has accepted a position as a member of this same committee. Dr. H e r b e r t L. Moon of Seattle has been made C h a i r m a n of the State Committee of Washington, to succeed Dr. J a y I. Durand. Dr. Stanley lqichols of A s h u r y P a r k lms succeeded Dr. J o s e p h H. Marcus as State Chairman in New Jersey.