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OCTOBER, 1893 
A STUDY IN SCARLET FEVER: APPARENT TRANSMISSION 
OF IMMUNITY BY THE INOCULATION OF 
HUMAN BLOOD SERUM. 
By Albert S. Ashmead, M.D., 
New York. A STUDY IN SCARLET FEVER: APPARENT TRANSMISSION 
OF IMMUNITY BY THE INOCULATION OF 
HUMAN BLOOD SERUM. 
Albert S. Ashmead, M.D., 
New York, 
On June i, I was called to attend Willie D., aged 4% years, whom 
I found suffering from scarlet fever. He had been stricken two days 
before with severe vomiting, prostration and high fever. The night of 
May 31 the eruption had appeared. When I saw him he was wdldly 
delirious ; vomiting had persisted all the time ; he was restless ; tem- 
perature 104° F.; pulse, 130; eruption appearing generally over the 
body, face pale, features pinched, tonsils swollen, fauces and throat 
intensely red, strawberry tongue. I gave him ten grains of citrate of 
potash every two hours, and anointed the body with carbolic vaseline, 
3ss to ?ij, and injected in his fore-arm, just below the elbow, thirty 
minims of pure blood serum, taken from a blister on the breast of my 
own child, who had had scarlet fever five years before, having been 
under the care of Dr. Edward L. Partridge. The sister of my patient, 
Lizzie D., aged 2 years and 9 months, had never had scarlet fever; she 
slept with her brother. I injected a portion of the same blood serum 
into her arm as a preventive. On June 2 the efflorescence on the 
boy was full and intense, and very dusky ; in fact, the most intense 
eruption I have ever seen ; it was complete from head to foot; tem- 
perature in axilla, ioi° F.; in rectum, 101%0 F.; the glands at the 
angle of the jaw were swollen. A second injection was given the 
patient, and the girl was also inoculated again. On June 3 the boy's 
eruption was fading; temperature in axilla, ioo° F.; in rectum, 
100%0 F.; pulse, 120; several scars on the body were very white; 
boy and girl both injected again. On June 4 desquamation plentiful 
at the point of insertion of the serum; the eruption has rapidly faded, 
and almost disappeared; temperature, ioo° F. in axilla, ioo%° F. in 
the rectum; boy and girl both injected. June 5, desquamation 
spreading over legs, arms and neck; throat symptoms disappearing; 
the only remnant of eruption is over the back and the front of the 
body; temperature in axilla, 99%° F.; in rectum, loOyV F.; pulse, 
120; the boy eats heartily; both boy and girl received another injec- 2 
Albert S. Ashmead. 
tion. June 6, desquamation general, scaling in large sheets; throat 
symptoms have entirely disappeared ; appetite good ; temperature in 
axilla, 99X0 F-! in rectum, ioo° F. ; both receive an injection. 
June 7, desquamation rapidly ending; temperature in axilla, F.; 
in rectum, 99777° F.; pulse, 108; appetite good; both receive injec- 
tion. June 8, normal temperature; pulse, 96; no redness in fauces; 
desquamation ending ; appetite excellent; injections repeated. June 9, 
temperature normal; pulse, 96; desquamation almost ended; the 
boy passed at one time ten ounces of urine; the passage of urine has 
been plentiful throughout; injections given. June 11, temperature 
normal; pulse, 96; desquamation ended, except on the index fingers 
and calf of one leg; no throat symptoms ; child dressed and moving 
about as usual; no one would take him for a convalescent; injec- 
tions repeated. June 13, evidences of dropsy in the boy's face; 
examination of urine shows presence of albumin; specific gravity, 
1025; gave him digitalis, tincture of iron and muriate of pilocarpine; 
ordered hot baths at night, and placed him on an exclusive milk diet. 
June 15, swelling in the face diminished ; no swelling in the legs ; very 
smoky urine ; only two ounces of urine passed in the last twenty-four 
hours. June 16, about the same. June 17, no fever; increased 
swelling of face; no swelling of legs; passed two and a half ounces 
of urine in the last twenty-four hours; vomiting. June 18, vomited 
four times; face very much swollen; some pitting in the legs ; three 
ounces of urine passed in twenty-four hours; some desquamation on 
one palm ; none on the soles; applied a blister of cantharides to the 
loins, three by six inches; has had a good passage since giving him 
ten grains of compound jalap powder. June 18, evening; surprising 
diminution of dropsy ; passed five ounces of urine since morning; skin 
moist; he had two bowel movements; blister opened and dressed. 
Fifteen minims of this blister serum inoculated in the arm of the 
sister, and fifteen minims inoculated in a white rabbit; fifteen minims 
of precipitated albumin from the urine of the boy also inoculated in a 
second white rabbit. 
The analyses of five specimens of urine taken on the third to fifth 
days of desquamation, give these results : 
(1) Specific gravity 1025, strongly acid, oil globules abundant in 
quantity, a trace of epithelial debris from the kidney, a few epithelial 
casts, a few granular casts (narrow fragments), a trace of oxalate of 
lime, a few blood casts (narrow fragments). 
(2) Strongly acid, specific gravity 1025, numerous narrow con- 
voluted granular casts, a trace of epithelium from mucous surface of the 
ibladder, diplococci numerous. 
(3) Granular casts abundant. A Study in Scarlet Fever. 
3 
(4) Epithelial fragments, a few broad casts, numerous granular 
(narrow) casts, a trace of phosphate of lime, a trace of pus corpuscles. 
(5) A few granular casts, sulphuric acid .8, water 94 (to f?i), a 
trace of urate of soda. 
In every one of these specimens the polariscope1 showed 3 per 
cent, albumin. In each specimen there were about 2.06 grains urea to 
the fluid ounce. 
June 19, passed in the night three ounces of urine; in the even- 
ing, facial dropsy was much diminished; less albumin in the urine ; 
passed two ounces this morning. June 20, five ounces of urine passed 
since last night's visit; slept well; less dropsy in the face ; some in 
the legs still; albumin steadily diminishing; absolute milk diet con- 
tinued. An analysis of the blood serum of the patient, which was 
inoculated into the girl and the rabbit without producing sickness in 
either, showed streptococci pyogenes in abundance, and leucocytes 
without ameboid movement. June 21, boy passed eleven ounces of 
urine. June 22; eighteen ounces of urine passed, rapid convalescence 
evidenced by the appearance in excessive quantity of urates of ammonia 
and soda, and acicular uric acid crystals. 
June 26, the white rabbit subcutaneously inoculated with the 
albumin of the urine, and which had been ailing ever since the opera- 
tion, died. 
Examination of the blood serum taken from the boy June 18, 
by the Doremus' apparatus, showed 4.06 grains of nitrogen to the 
fluid ounce. Abundant streptococci and spores were seen in the 
microscope, with yk-inch objective (1500 diameters). Leucocytes in 
excessive quantity, granular matter well marked and well defined in out- 
line. The streptococci were freely scattered in the field of observation. 
Thomas K., aged 6 years and 8 months, on the eleventh day of 
desquamation, fingers peeling like gloves; one fold of skin en masse 
from the buttocks ; throat symptoms very intense ; diphtheritic mem- 
brane on one tonsil; no albumin in urine. Blood serum examined 
under the microscope on the thirteenth day of the disease; 1000 
diameters homogeneous immersion lens) shows leucocytes 
with ameboid movement, granular matter not marked, and indefinite 
in outline; no streptococci; urine neutral ; specific gravity 1010, 
ninety-seven parts of water. Ten minims of this serum was inoculated 
into the little girl, the sister of the first case of scarlet fever. No 
infection resulted. 
Blood serum in the second case of scarlet fever, seventeenth day of 
the disease, 1000 diameters (y inch homogeneous immersion objective) 
shows in the leucocytes protoplasmic movement very active, very 
1 Wentskie-Schiebler. Franz Schmidt and Hoensch, Berlin. 4 
Albert S. Ashmead. 
distinct; granular matter well marked. Doremus' apparatus shows 
in this serum 1.23 grains of nitrogen to the fluid ounce. Examination 
of the urine of the same case, on the same day, gives specific gravity 
1012, acid, 95 parts of water, urate of soda and oxalate of lime, and no 
albumin by one to 40,000 test, Millard's solution. 
Examination of a drop of blood of this case on the same day 
(seventeenth), that is at the full stage of desquamation, 1000 diameters 
( objective homogeneous immersion) shows the leucocytes 
actively at work; ameboid movement very distinct; granular matter 
well defined; fibrin coarse in texture, excessive in quantity; red cor- 
puscles slightly plastic and in irregular masses or hummocks and not 
inclined to form nummular rolls. It is now sixty days since the first 
boy developed scarlet fever. His serum when inoculated into his 
sister, who had never had scarlet fever and whose association with her 
brother has been of the closest kind throughout, no isolation whatever 
being made, sleeping with him, fondling and kissing him, did not 
communicate the disease. 
It may be objected that this test was not a fair one, as the immu- 
nized blood serum from my own child was also inoculated into the boy, 
and that if there was any protective principle it might have acted on 
the boy as well as on the girl. I therefore used a further test. I took 
the blood serum of the second case of scarlet fever and inoculated it in 
the girl. She did not take scarlet fever. 
There are in the first case of scarlet fever the following points of 
interest from a clinical point of view : The quick fall of temperature 
following the first insertion of immunized blood serum, its continuance 
at about ioo° F., the early commencement of the desquamative stage, 
its commencement at the points of inoculation and its early complete 
ending. 
The death of the rabbit inoculated with albumin would at the first 
blush indicate a toxic principle in the albumin of scarlet fever, but 
subsequent careful experiments with this same albumin precipitated 
with alcohol filtered through absorbent cotton, washed with distilled 
water and evaporated, failed of a toxic result when inoculated in a 
white mouse, white rabbit and guinea pig. The presence of nitrogen 
in excess in the blood serum of the two cases with and without the 
presence of albumin in the urine, evicently has a connection with the 
disease. The white corpuscles of the blood seem, therefore, to have in 
scarlet fever the function of carrying nitrogen,1 the product of decom- 
posing tissue, to the emunctory organs, the skin and kidneys. They 
1 The sweat of man contains 0,452 per cent, albumin. The total nitrogen is more considerable 
than the nitrogen of the urea in the sweat, the excedent of nitrogen belongs in great part to tl e 
albumen with albuminates of the sweat, Gaube, Paris. Hydrozymases and albumen in human 
and animal perspiration. A Study in Scarlet Fever. 
5 
are, therefore, not alone phagocytes, they are chemists and scavengers, 
and in their ameboid movement they encircle particles of foreign 
matters or organisms, not to feed on them, but to carry them to the 
dumping grounds of the economy.1 In their normal emigration 
through the capillary walls they carry out the refuse and then return 
from the lymph spaces to their regular habitat. 
A poison, like that of scarlet fever, entering from the air into the 
current of blood through the mouth and lungs, throws possibly an 
extraordinary amount of work upon the leucocytes, and in the struggle, 
if there is any interference with their work of elimination through the 
natural outlet, the skin, such as imperfect desquamation, contraction 
of the capillaries by cold, too short a period of desquamation, the leu- 
cocytes perish and give up their serum albumin to the blood. This 
albumin probably is the albumin eliminated through the kidneys. The 
appearance of albumin in scarlatinal urine, therefore, means a destruc- 
tion of leucocytes. These leucocytes also are carriers of nitrogen, and 
the appearance of an excess of nitrogen in scarlatinal blood serum 
means an increase of katabolisim, in the skin especially. 
I will give my conclusions as succinctly as possible. It is probable 
that the first inoculation of immune blood serum gave protection to the 
girl. Therefore, there was no necessity for repeated inoculation. I 
think I am justified in believing that the assertion of Ogata and Jasu- 
hara, of Tokio, that even one drop oi immune frog's blood, or half a 
drop of immune dog's blood, is sufficient to protect a mouse from the 
fatal effect of an anthrax inoculation, states at least a probable fact. 
The streptococci had nothing to do with the disease. 
The boy's serum, on the eighteenth day, when inoculated into his 
sister, was not infectious. 
The albumin of scarlatinal nephritis is not toxic. 
The inoculation of scarlet fever with immunized blood serum is not 
curative. 
The inoculation without infection of the girl with ten minims of 
blood serum from the second boy, who had not been immunized, appar- 
ently proves the immunity conferred by the first inoculation. 
I add two practical suggestions : The application of a blister over 
the kidneys in scarlatinal nephritis is followed by good effect. 
The earliest symptom of improvement in this complication is the 
appearance of urates and uric acid crystals in the urine. 
1 It is an error, I am sure, to consider the nuclein of a white corpuscle, the nitrogenous part 
of it, as belonging to the corpuscle ; it is only a temporary content, which; is being carried out of 
the body. But it is rightly believed that the serum-albumin of a white corpuscle, which is the 
proteid left after the removal of paraglobulin, is a part of the corpuscle. This may or may not 
become a tox-albumin. It does become a tox-albumin in the rigor mortis.