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Study of the Dick test in scarlet fever. A consideration of the anomalies of the test and of the significance of skin sensitivity to products of the haemolytic streptococcus

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Date
1933
Author
McGibbon, John P.
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Abstract
 
 
(Part I ). #1. The test of susceptibility to scarlet fever first introduced by the Dicks has been described. Its relationship to the Schultz- Charlton -phenomenon and to the etiology of scarlet fever has been considered. #2. The divergent results obtained by other workers have been briefly presented. #3. 160 cases of scarlet fever have been skin tested at weekly intervals. The methods adopted and the results obtained have been described and summarised. #4. The anomalies of the test as noted in these cases and as described by other workers have been reviewed. #5. An attemtt has been made to assess the relative importance of these anomalies. #6. The conception of scarlet fever as an allergic phenomenon has been considered. From a survey of this work it seems possible to form the following conclusions: - 1. That in general the Dick test forms a reliable index of susceptibility to scarlet fever is in my opinion unquestionable. 2. The paradoxical behaviour of the test has been to some extent exaggerated. It is possible that some of the anomalous features described may be due to the development of an allergic state. 3. Scarlet fever is due to infection with a haemolytic streptococcus. It is not a disease entity, but is a clinical syndrome, of which an eruption of particular character and distribution forms an essential feature. The continued use of such an expression as "Scarlatina sine Eruptione" can only lead to confusion. In any consideration of the value of the Dick test some such definition as the above must be accepted by all workers, if comparable results are to be obtained. 4. If scarlet fever is to follow such an infection, three conditions are necessary: - (1) The infecting streptococcus must be highly toxigenic. (2) The host must have an insufficient general immunity. (3) The skin of the infected person must be susceptible to the toxin. General and local resistance are not necessarily parallel. 5. The fact that in certain persons and at certain periods of life they do not run parallel does not form a sufficient reason for the discarding of the view that scarlet fever is caused by a specific toxin. 6. The conception of scarlet fever as an allergic phenomenon is based on a series of inconclusive animal experiments, a fallacious assumption that general and local resistance must coincide, and a too destructive criticism of the Dick test. 7. The conception of scarlet fever as a specific toxaemia is more convincing. From the available evidence it is at present the only one acceptable. * * * * * * * * * * * * * * * * (Part II.) 1. A condition of hypersensitiveness to products of the haemolytic streptococcus has been described by various writers. It has been possible to demonstrate the development of this allergic state during the course of scarlet fever. 2. The preparation has been described of an extract representing the soluble intracellular Products of the organism freed from diffusible substances. 3. Using this material the skin reactions in 74 cases of scarlet fever have been studied. In the first week of the illness all the reactions were negative or feebly developed, but in the fourth week 66 patients (almost 90 %) gave positive reactions. 4. 28 of these cases were tested at weekly intervals; in these cases the positive reaction was sometimes present in the second, and usually present in the third week. 5. Age is an imoortant factor in the development of this skin sensitivity. All the cases over 7 years of age developed the allergic reaction. The older age groups tended to become positive at an earlier stage than the younger children and their sensitivity became greater as judged by the intensity of the skin reactions. 6. Normal persons are frequently sensitive to this type of preparation, but young children are rarely so. The reactions noted after scarlet fever cannot be regarded, therefore, as a recrudescence of a pre- existing skin sensitiveness. 7. Repeated skin testing in control cases produces no such increase in reaction. 8. Although in many cases skin sensitivity to H.S.E. and Dick toxin is inversely related, this relationship is not a constant one. 9. The possible significance of this allergic state in the causation of scarlatinal nephritis and scarlatinal arthritis needs further study. 10. A case of scarlatinal arthritis with a particul: :arly intense skin reaction has been described. This would appear to sharply differentiate scarlatinal arthritis from acute rheumatism. 11. The persistence of this allergic condition may be of importance in the development of the "rheumatic state ". This possibility has been discussed. 3 cases tested a year later have retained their sensitivity to H.S.E. i of these cases has developed chorea. 12. 160 persons not suffering from scarlet fever have also been skin tested with H.S.L. Age has an important influence on the results. The reaction appears to be inhibited in chronic cardiac disease and wasting conditions,but to a less extent in acute infections unless these be of exceptional severity. 13. The results in erysipelas contrast sharply with those in scarlet fever. In erysipelas the skin teaction is positive on admission to hospital and appears to remain so at all stages of the disease. In the absence of extreme illness a negative reaction in an adult patient should question the diagnosis of erysipelas. In young patients the skin reaction in this disease is still unknown. 14. A proportion of cases of puerperal infection show an increasing sensitivity as in scarlet fever. The possibility of this being a recrudescence of a pre- existing skin sensitiveness is difficult to exclude unless the reaction to H.S.E. be tested before infection. The relationship between the skin changes and the infecting organism needs further study. 15. At the present stage the work is in so many respects incomplete that conclusions must be necessarily limited. It will only be possible to assess the importance of the results already obtained by following up each new line of investigation as it suggests itself, while tr;ing not to lose our perspective of the problem as a whole. 16. It is doubtful if we can hope to make much real progress until the mechanism of these skin reactions is better understood, and their significance in relation to the vital processes in general better appreciated.
 
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http://hdl.handle.net/1842/35236
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