536

REVACCINATION IN ADULTS

SIR,-Dr. J. C. Broom’s paper (March 22) promptsus to report some observations made in the Middle Eastin 1945.

Lieut.-Colonel (now Professor) R. S. Illingworth hadpointed out to us that a typical " reaction of immunity "was evoked by a heat-killed vaccine. To verify his state-ment a series of 20 previously vaccinated patients wererevaccinated with both heated and unheated vaccine bya standardised technique with a single scratch 1 cm. inlength. The response to both heated and unheatedvaccines was similar in each case and had the character-istics of the " reaction of immunity." In a secondseries of 20 cases where the areas of erythema wereplotted no constant differences between reactions toheated and unheated vaccine could be demonstrated.The figure shows the findings in 5 representative cases.To prove that the virus had been killed, material

from the same batch of heated vaccine was used to vac-cinate 10 previously unvaccinated infants. In no casedid a reaction occur ; later these infants were successfully-

Areas of erythema after vaccination with unheated and heated vaccinelymph.

vaccinated with unheated vaccine. Intradermal tests onrabbits also showed that living virus was no longerpresent after heating.As calf-lymph vaccine had been employed in these

experiments the agents possibly responsible for thereactions were bovine protein, contaminant bacteria, thepreservative added to the vaccine, or the proteins of thevirus bodies themselves. A series of 10 previouslyvaccinated patients were accordingly revaccinated withheated vaccine, unheated vaccine, bovine serum, and thepreservative. Reactions were noted only with the first 2.Dr. Dennis, of the American University of Beirut, kindlysupplied us with vaccine prepared by culture on chick-embryo membrane, the bacterial content of which wasnegligible. In 10 previously vaccinated patients similarA reactions of immunity " were obtained to this vaccineboth when heated and unheated. From these observa-tions we concluded that the " reaction of immunity"was an allergic response to the proteins of the virus bodiesin an individual sensitised by previous vaccination.

Circumstances had prevented us from reading therelevant published work ; but at this stage we discoveredthat similar observations had been made in 1901 by vonPirquet, who had reached the same conclusion. Wetherefore pursued our somewhat naive investigationsno further, believing that we had been in ignorance offacts well known to better-qualified workers in thisfield.

If our conclusions were correct it followed that the" reaction of immunity " in fact only indicated that thepatient was immune to variola when the vaccine employedwas known to be potent and viable. This explained ourprevious experiences of seeing patients in whom we hadourselves noted a " reaction of immunity " develop fatalsmallpox within two months of vaccination.Dr. Broom is clearly aware of the problem, but he has

noted a considerable number of cases in which unheatedlymph gave a " reaction of immunity " while heatedlymph gave no reaction. Our experience was differentfrom this : in a few a "reaction of immunity" wasgiven by unheated, but not by heated, lymph; in aboutan equal number the reverse was noted. We attributed

these discrepancies to faults in our technique, and repeti-tion, by producing similar reactions with both heated andunheated lymph, confirmed our view. Dr. Broom admitsthat the reaction to heated lymph may " closly simulate "that to unheated ; we concluded that the two wereindistinguishable. We share his uneasiness about certi-fication ; on several occasions we have seen the senseof security engendered by a " reaction of immunity "

prove disastrously false. London, W.1.

Leeds.

RONALD BODLEY SCOTT

R. P. WARIN.

CHEST DISEASE IN RAND MINERS

SIR,-In their letter of Feb. 8 Dr. Frazer and Dr.Walker rightly say that we have a miniature radiographyplant at the Witwatersrand Native Labour AssociationHospital, which has now been. in operation for severalyears. (Like them, we consider that our miniatures areof a verv high standard, as also are the large X-ray filmstaken to check the abnormalities seen in the miniature ..radiographs.) They were wrongly informed, however,that native workers suffering from phthisis may continueto work if they choose to do so. No native mine labourerfound to be suffering from pulmonary tuberculosis and/orsilicosis is allowed to continue working at the mines ; heis compensated and repatriated at the expense of themines. The compensation paid is, for silicosis, a sumequal to 36 times the amount of his monthly earnings,or .S180, whichever of the two amounts is the greater.Similar compensation is paid for pulmonary tuberculosiswhere the labourer has been engaged in a dusty miningoccupation for 8 or more years. Where the labourer isfound to be suffering from, pulmonary tuberculosis afterhaving worked in a dusty occupation for 30 days orlonger, he is given an amount equal to 20 times thesum of his monthly earnings, or 2100, whichever of thetwo amounts is the greater.

Dr. Frazer and Dr. Walker add that " during a briefvisit to the W.N.L.A. Hospital, no case of chest diseasewas seen." This seems strange, as we detain a largenumber of patients in hospital for sputum tests and otherinvestigations. Apart from these, all patients on themines who are suspected to be suffering from pulmonarytuberculosis and/or silicosis, after X-ray, clinical, or

sputum investigation, or loss of weight, are sent to ourhospital and detained here for examination by themedical officers of the Silicosis Medical Bureau, with aview to possible compensation.

- -

Witwatersrand Native LabourAssociation, Ltd., Johannesburg.

FRANK RETIEFChief Medical Officer.

BETTER CARE FOR THE HOMELESS CHILD

SiR,—Your annotation of April 5 suggests that thereis fairly general agreement with the recommendations ofthe Curtis Committee. But it is in fact surprising thatmore written protests have not appeared from workers inpublic-health, medical, and educational circles consideringthe extent of the disagreement which exists. The largestsingle group of children mentioned in the report is thatin public-assistance institutions. It is remarked withsurprise that 60 % of these children are short-stayadmissions-e.g., children admitted because the motheris having a baby. To this extent the total figures areinflated, for this group can hardly be described as

" deprived children." The committee consider thatmore accommodation for these short-stay childrenis badly needed, although they remark that there wasample accommodation in children’s homes generallybefore the war. The overcrowding of the public-assistanceinstitutions, therefore, seems to have developed withthe war, when women were encouraged to send theirchildren (even those of 2 years) into institutions whilethey either went to work or had a baby, and there waslittle warning to the mother that it might have a badeffect on the child’s emotional development. The legacyof 5000 homeless evacuees tells its own tale. Somepropaganda in reverse to emphasise the importance ofkeeping the child in its own or a, relative’s home wherethis is at all possible might now be instituted, with aquotation from the Curtis report on " the extremeseriousness of taking a child away from even an indifferenthome." To a young child even two weeks is a long time.

537

The Government’s decision to make the Home Officethe responsible central department is itself remarkable,since, of the three central departments concerned, thisis the only one without adequate trained visiting staffat the local-authority level. 11

At a guess I should say the visiting of individualchildren for fostering, adoption, and boarding-out willcontinue to be done by the same people who do it atpresent-namely, health visitors, school nurses, and school-attendance officers, with the added complication thatfor this part of their work they will apparently beresponsible to the Home Office through the children’sofficer. The Curtis Committee propose that this officershould be an important administrative official of thecouncil, not on the staff of any other department, withapproximately 500 children under her care. As it will notbe practicable for her to know and keep in touch withthem all (although the personal touch is the main argu-ment for her appointment) she will allocate groups ofchildren to her subordinates. A boarding-out visitor isto be responsible for the supervision of 100-150 children,each to be visited at least once in three months. Sheis to be a superior visitor (? a psychiatric social worker)-not a mere health visitor-and this may explain why sheis apparently only to do two or three visits a day. Yethealth visitors have at least 1000 children to visit, andlocal authorities have found it almost impossible to fillvacancies because of the shortage. Are psychiatric socialworkers more plentiful ?Whether one agrees or disagrees in principle with the

recommendations of the Curtis report the main singlecriticism is that it considers the matter as if in a vacuum.It ignores the fact that there is a shortage in almost everysphere of trained professional women. The inspectingstaff of the central government department must beincreased, children’s officers must be appointed. Butwhere will they be drawn from ? Health visitors,nursery-school teachers, psychiatric social workers,matrons-all are in desperately short supply. Thus weare faced with an increase at the supervisory and inspec-torial levels, with a resulting decrease in the alreadyoverworked staffs who do the spadework.Woodford Green, Essex. HILDA MENZIES.

SAND-FLY FEVER

SzR,-The article of April 5 by Dr. John Fleming,Major Bignall, and Captain Blades was of great interestto me as I witnessed a large series of similar cases in amilitary hospital in Athens during the summer of 1941.These cases were considered not to be true sand-fly

fever for three reasons : (1) the almost clock-likeregularity of three days’ duration which characterisedthe outbreak and which is not typical of sand-fly fever ;(2) the absence of really severe headache, which is cer-tainly present in genuine sand-fly fever ; and (3) theabsence of the well-known depression and astheniawhich characteristically follow sand-fly fever.The Greek doctors, who are used to these epidemics,

have named it the three-day fever ; and it was theiropinion that it was not due to the sand-fly. One suggestionmade at the time was that it was an abortive form ofanterior poliomyelitis, of which there was a concurrentepidemic. The outbreak also coincided with the sea-bathing season.

I suggest that among cases of short-term - pyrexiawhich tend to be labelled sand-fly fever there is a

separate entity-" p.u.o., three-day type "-of whoseaetiology we are at present ignorant.’ To label such casessand-fly fever is to hinder progress.

Brighton. EDWARD W. LINDECK.

SrR,-The review by Fleming, Bignall, and Bladesmust have evoked wistful memories in those of us whogave some minutes every summer night to hunting inthe folds and corners of the mosquito-net for the elusiveand diaphanous flies, only to wake on the morrow andfind that quite a few had escaped our search and werenow showing up all too easily by the large red blob ofour blood in their bodies.The sand-fly set us a nice problem in differential

diagnosis. When a fairly large outbreak of sand-fly feverbegan in Greece, at a time when everybody was acutelysmallpox-conscious, 3 cases’ of ?smallpox were admitted

to the isolation ward of our hospital. Their history wasone of a three-day fever, and they showed a petechialrash, most marked over the feet, including the soles,and less marked over the legs, hands, and face. The

history and the distribution of - the rash were in factreminiscent of smallpox, but the rash was quite super-ficial and slightly irritating and itching. Our diagnosisof sand-fly fever and insect bites, probably caused bythe phlebotomus, was borne out later in this outbreakwhen we saw a considerable number of similar cases withpetechiae over exposed parts of the body. We never sawweal formations in the patients exhibiting petechiae.The admission of ?smallpox cases was of course known

to our higher administrative authorities, who, rightlyconscious of their responsibility, were not so easilypersuaded to regard these cases lightly. There were anumber of consultations with Army authorities andGreek medical notables. In fact we were much in thelimelight for some days and gained an interestingexperience, at the cost of some disruption of communica-tions to our " smallpox-infested " community.

London, W.1. P. F. MEYER.

STEVENS-JOHNSON SYNDROME

SIR,-The Commission on Acute Respiratory Diseasesof the U.S. Army Medical Corps,l reporting 6 cases ofStevens-Johnson syndrome and inoculation studies fromnecropsy material of a 7th, emphasise the frequency oflung lesions closely resembling primary atypical pneu-mohia ; in 2 of their 3 pneumonic cases cold agglutininswere present in significant titres. They cite J. H. Stanyonand W. P. Warner,2 who in a series of 17 cases foundnon-bacterial pneumonia in 14, with 2 fatalities showingwidespread pulmonary consolidation with a mononuclear-cell exudate. _

The disease, which is fairly uncommon, seems tocome in small epidemics. Hebra,3 who as early as 1860noted its association with pneumonia, thought that itwas commonest in April-May and October-November ;and Keil 4 reports that it is not rare in New York Cityduring spring and autumn. That there may be no severecases for years at a time is suggested by the absenceof any example of it in Jonathan Hutchinson’s Archivesof Surgery, which are a good source of reports on unusualdermatological conditions in the 1890’s.

Dr. Nellen (March 15) correctly quotes Rosenberg andRosenberg as alleging that the first cases were describedin 1822 by Alibert and Bazin. The Rosenbergs give astheir source a thesis,5 which I have so far been unableto trace ; but as Bazin in 1822 was at the tender ageof 15 it seems that the Rosenbergs made a slip. Lookingthrough Alibert’s Monographie des Dermatoses,6 I didnot find anything relevant to the subject; but Bazin’shydroa vésiculeux 7 most probably relates to thecondition.Without having a special grudge against eponymous

titles I feel this particular one is unwarranted. In hisscholarly paper Keil discusses contributions to thissubject back to 1860 ; perusal of it will dispel the beliefthat Stevens and Johnson contributed something essen-tially new. The Commission on Acute RespiratoryDiseases also consider that this eponym has no historicaljustification.None of the many terms used for it is wholly satis-

factory. Hebra coined the term " erythema multiformeexudativum," all his cases having had only cutaneousmanifestations. Later writers have often used termsaccording to the local signs (dermato-stomatitis ; gingivo-stomatitis ; atypical ulcerative membranous stomatitis ;mucosal respiratory syndrome). Even the more

embracing term, " muco-cutaneous fever," is not ideal,

for there may be no fever and tissues other than skinand mucous membranes may be involved. Hebra’soriginal term is still more often used than others byauthors describing cases with extra-cutaneous manifesta-

1. Arch. intern. Med. 1946, 78, 687.2. Canad. med. Ass. J. 1945, 53, 427.3. Handbuch der speziellen Pathologie und Therapie (R. Virchow),

Erlangen, 1860, vol. 3.4. Keil, H. Ann. intern. Med. 1940, 14, 449.5. Beaudonnet, B. Thèse de Paris, 1894, no. 354.6. Paris, 1832.7. Leçons théoriques et cliniques sur les affections génériques dela peau, Paris, 1862-1865 ; quoted by Keil.