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ENTERIC FEVER AND PROTECTIVE INOCULATION.
1326 him on July 17th, which I did, and made the following notes :"Female adult, aged 27, vaccinated in infancy. Had some conbefore eruption stitutional symptoms (backache, fever, &c.) appeared; was in contact with another adult with rash two weeks ago. Distribution and character of rash : Vesicular eruption of face fairly profuse on forehead, a few vesicles on both wrists, one on dorsum of left hand, none on ankles, one in palm of left hand. A few scattered vesicles on the back, and on the proximal parts of the limbs. Eruption consists of papules, vesicles, and
(8) Age-incidence in moderately well vaccinated communities.Varicella most common in early childhood; variola in persons over 15. (Occurrence of several cases of varicelloid rash among persons over 15 at once suggests variola rather than varicella.) (9) While taking all common-sense precautions, in view of the drastic action arising out of notification of small-pox, suspend diagnosis and notification until evidence is clear. -
Outbreaks like this outbreak of small-pox in East Anglia in 1919 are additional evidence in favour of the pustules said to have come out in crops.’ arguments adduced in my book on " Evolution and I thought it best to consider the case as more probably Disease " (John Wright and Co., Bristol). I am, Sir, yours faithfully, variola, asked Dr. J. B. Stevens to vaccinate me on the spot, also to vaccinate the patient as an aid to diagnosis, J. T. C. NASH, M.D. Edin., D.P.H. Camb., and other members of the household as a precaution. I Norwich, Dec. 8th, 1920. County M.O.H., Norfolk. then suggested that a visit to the Beccles cases would be useful, and through the kindness of the M.O.H. (Dr. G. R. Fox) and his partner (Dr. H. Wood-Hill) saw a ENTERIC FEVER AND PROTECTIVE "
’
number. Some were unmistakable cases of small-pox (like the photographs appended to Dr. Copeman’s valuable report). One or two had had so slight an eruption (one or two pocks) that seen by themselves and without a history of contact a diagnosis would have been far from easy. The Beccles cases seen by us absolutely clinched the diagnosis of small-pox in the Geldeston case, and also as regards the Gillingham cases (which I On July 23rd Dr. Stevens wrote me: had not seen). " All the vaccinations (Geldeston) have taken except that of the patient." One contact, adult male, a brother who had been exposed to infection since July 9th, and was successfully vaccinated on the 17th, developed a varioloid rash on the 30th. These vaccination results confirmed the usual experience that developed variola protects against vaccination, while variola and vaccinia may incubate at the same time with modification of the ultiNo further cases occurred mate variolous attack. among the contacts. A month later a visitor from London, male, aged 18, who had stayed a night in Beccles, August llth, proceeded to another village (Hales) in Norfolk. On the 19th he noticed a " spot " on one hand. On the 21st he had rash on forehead, trunk, and limbs. On the 23rd, at Dr. Stevens’s request, I saw this lad. My clinical notes run :Papules and vesicles abundant on face (a few on scalp), also seen on palate, back, chest, abdomen, and limbs. Fairly profuse (but discrete) on proximal parts of limbs, very few on wrists, but some in palms and soles. Some vesicles multiloculated and others clear, large, rounded, and unilocular without areola. The relative abundance of the pocks on face and back, the fact of some pocks in palms and soles, together with evidence of constitutional prostration, weighed the evidence in favour of variola, notwithstanding that the general appearance and distribution of many of the vesicles were more suggestive of varicella." The case was removed to hospital and contacts were vaccinated. It is interesting to note that on Sept. 4th the diagnosis of small-pox had not been confirmed, but that on Oct. 9th the superintendent of the small-pox hospital informed Dr. Stevens that he had finally come to the conclusion that the case was one of small-pox. The difficulties of diagnosis and the mildness of the type of small-pox in this outbreak are fully dealt with by Dr. Copeman. It may be of service to repeat that diagnosis must be based on all the available evidence; not on any one point to the exclusion of others. My experience in this outbreak has induced me to formulate the following as aids to diagnosis in similar mild outbreaks :"
(1) In any case of doubtful nature always bear in mind the possibility of small-pox. (2) Some cases of small-pox commence with a prodromal erythematous or petechial rash. The sites of selection of these prodromal rashes are about the flexures of the groins, shoulders, and knees. (3) The distribution of the papules, vesicles, and pustules of the ordinary small-pox rash when fairly abundant and unmodified by recent vaccination is generally chiefly on forehead, back, and distal parts of limbs (wrists and ankles). In some cases there is no excess of rash on distal parts of limbs. (When modified by recent vaccination distribution of rash is also modified.) (4) Both variola and varicella rash may come out in crops and show papular and vesicular elements at the same time. (5) Character of elements.-The vesicles of small-pox, when fully developed, are larger and rounder than those of varicella, even though they may appear to be superficial and filled with clear lymph. Umbilication is not a distinctive character. (6) Incubation period.-Shorter in variola than in varicella. (7) Constitutional symptoms at onset.-Backache, three days’ fever before rash, and prostration, generally marked in variola ; only exceptionally so in varicella.
INOCULATION. To the Editor of THE LANCET.
,
SIR,-In THE LANCET for Dec. llth LieutenantJ. R. Harper, R.A.M.C., gives his experience Colonel " ,
of
The Clinical
Aspects
of Enteric Group Infection as Inoculation." It is interesting find that a clinical observer, with so considerable an experience, does not regard atypical enteric fever as altogether a myth, nor consider serological evidence to be entirely unreliable. It is not, however, with this side of the question that I am at present concerned. Colonel Harper, in comparing the relative freedom of our troops from enteric infections during the recent war with the high incidence and heavy mortality from the same cause in the South African campaign, gives 7423 cases as the official figure for the total incidence of infections of this type among our armies in France. In examining a considerable series of febrile cases invalided from the Western front between October, 1916, and March, 1919, we were led to the conclusion that a certain proportion of atypical enteric infections were probably escaping detection in France, a thing which appeared to us to be unavoidable under the exigencies of warfare. The object which we had in view in undertaking the investigation, and the conclusions to which we came may be summarised by two quotations from our report to the Medical Research Council.l
Modified by Protective
to
" The epidemiological facts of the war should provide data of the greatest interest; and it will be of vital importance to determine whether the cases actually diagnosed as enteric give a correct picture of the incidence of this type of infection among our army in France, or whether there must be added some considerable number of cases which have escaped diagnosis in the early stages and have then gone to swell the large class of undiagnosed pyrexias. A true answer can only be obtained by the close examination of comparatively small samples of cases, and the deduction of a factor which must be applied to the whole mass of undiagnosed pyrexial conditions. Whether it will be possible to arrive at a sound judgment on this matter remains to be seen. This investigation yields a tentative answer which will be confirmed or refuted by .the accumulation of evidence obtained by other workers." " It is probable that taking the whole period, October, 1916, to 1919, between ;5 and 7 per cent. of those cases which were March, invalided to this country from the Western front, suffering or convalescent from undiagnosed febrile conditions, were in reality examples of atypical enteric infection. The percentage of undiagnosed enteric cases was probably higher than this average the earlier part of this period, and lower during the figure during later. This conclusion is based almost entirely on serological and must stand or fall by the reliability of this method evidence, of diagnosis." If these conclusions be sound, there is, I think, an be drawn from them. They would indicate that the incidence of enteric infection was far greater than the figures for the diagnosed cases suggest, while they would emphasise the effect of prophylactic inoculation in transforming a disease of high mortality into a relatively minor infection, and in preventing its epidemic spread. I am, Sir, yours faithfully, W. W. C. TOPLEY. Institute of Pathology, Charing Cross Hospital Medical School, Dec. 14th, 1920.
important lesson to
,
1 Topley, Platts, and Imrie : " A Report on the Probable Proportion of Enteric Infections among Undiagnosed Febrile Cases Invalided from the Western Front since October, 1916." Med. Res. Council, Spec. Rep. Series, No. 48. 1920.
(8) Age-incidence in moderately well vaccinated communities.Varicella most common in early childhood; variola in persons over 15. (Occurrence of several cases of varicelloid rash among persons over 15 at once suggests variola rather than varicella.) (9) While taking all common-sense precautions, in view of the drastic action arising out of notification of small-pox, suspend diagnosis and notification until evidence is clear. -
Outbreaks like this outbreak of small-pox in East Anglia in 1919 are additional evidence in favour of the pustules said to have come out in crops.’ arguments adduced in my book on " Evolution and I thought it best to consider the case as more probably Disease " (John Wright and Co., Bristol). I am, Sir, yours faithfully, variola, asked Dr. J. B. Stevens to vaccinate me on the spot, also to vaccinate the patient as an aid to diagnosis, J. T. C. NASH, M.D. Edin., D.P.H. Camb., and other members of the household as a precaution. I Norwich, Dec. 8th, 1920. County M.O.H., Norfolk. then suggested that a visit to the Beccles cases would be useful, and through the kindness of the M.O.H. (Dr. G. R. Fox) and his partner (Dr. H. Wood-Hill) saw a ENTERIC FEVER AND PROTECTIVE "
’
number. Some were unmistakable cases of small-pox (like the photographs appended to Dr. Copeman’s valuable report). One or two had had so slight an eruption (one or two pocks) that seen by themselves and without a history of contact a diagnosis would have been far from easy. The Beccles cases seen by us absolutely clinched the diagnosis of small-pox in the Geldeston case, and also as regards the Gillingham cases (which I On July 23rd Dr. Stevens wrote me: had not seen). " All the vaccinations (Geldeston) have taken except that of the patient." One contact, adult male, a brother who had been exposed to infection since July 9th, and was successfully vaccinated on the 17th, developed a varioloid rash on the 30th. These vaccination results confirmed the usual experience that developed variola protects against vaccination, while variola and vaccinia may incubate at the same time with modification of the ultiNo further cases occurred mate variolous attack. among the contacts. A month later a visitor from London, male, aged 18, who had stayed a night in Beccles, August llth, proceeded to another village (Hales) in Norfolk. On the 19th he noticed a " spot " on one hand. On the 21st he had rash on forehead, trunk, and limbs. On the 23rd, at Dr. Stevens’s request, I saw this lad. My clinical notes run :Papules and vesicles abundant on face (a few on scalp), also seen on palate, back, chest, abdomen, and limbs. Fairly profuse (but discrete) on proximal parts of limbs, very few on wrists, but some in palms and soles. Some vesicles multiloculated and others clear, large, rounded, and unilocular without areola. The relative abundance of the pocks on face and back, the fact of some pocks in palms and soles, together with evidence of constitutional prostration, weighed the evidence in favour of variola, notwithstanding that the general appearance and distribution of many of the vesicles were more suggestive of varicella." The case was removed to hospital and contacts were vaccinated. It is interesting to note that on Sept. 4th the diagnosis of small-pox had not been confirmed, but that on Oct. 9th the superintendent of the small-pox hospital informed Dr. Stevens that he had finally come to the conclusion that the case was one of small-pox. The difficulties of diagnosis and the mildness of the type of small-pox in this outbreak are fully dealt with by Dr. Copeman. It may be of service to repeat that diagnosis must be based on all the available evidence; not on any one point to the exclusion of others. My experience in this outbreak has induced me to formulate the following as aids to diagnosis in similar mild outbreaks :"
(1) In any case of doubtful nature always bear in mind the possibility of small-pox. (2) Some cases of small-pox commence with a prodromal erythematous or petechial rash. The sites of selection of these prodromal rashes are about the flexures of the groins, shoulders, and knees. (3) The distribution of the papules, vesicles, and pustules of the ordinary small-pox rash when fairly abundant and unmodified by recent vaccination is generally chiefly on forehead, back, and distal parts of limbs (wrists and ankles). In some cases there is no excess of rash on distal parts of limbs. (When modified by recent vaccination distribution of rash is also modified.) (4) Both variola and varicella rash may come out in crops and show papular and vesicular elements at the same time. (5) Character of elements.-The vesicles of small-pox, when fully developed, are larger and rounder than those of varicella, even though they may appear to be superficial and filled with clear lymph. Umbilication is not a distinctive character. (6) Incubation period.-Shorter in variola than in varicella. (7) Constitutional symptoms at onset.-Backache, three days’ fever before rash, and prostration, generally marked in variola ; only exceptionally so in varicella.
INOCULATION. To the Editor of THE LANCET.
,
SIR,-In THE LANCET for Dec. llth LieutenantJ. R. Harper, R.A.M.C., gives his experience Colonel " ,
of
The Clinical
Aspects
of Enteric Group Infection as Inoculation." It is interesting find that a clinical observer, with so considerable an experience, does not regard atypical enteric fever as altogether a myth, nor consider serological evidence to be entirely unreliable. It is not, however, with this side of the question that I am at present concerned. Colonel Harper, in comparing the relative freedom of our troops from enteric infections during the recent war with the high incidence and heavy mortality from the same cause in the South African campaign, gives 7423 cases as the official figure for the total incidence of infections of this type among our armies in France. In examining a considerable series of febrile cases invalided from the Western front between October, 1916, and March, 1919, we were led to the conclusion that a certain proportion of atypical enteric infections were probably escaping detection in France, a thing which appeared to us to be unavoidable under the exigencies of warfare. The object which we had in view in undertaking the investigation, and the conclusions to which we came may be summarised by two quotations from our report to the Medical Research Council.l
Modified by Protective
to
" The epidemiological facts of the war should provide data of the greatest interest; and it will be of vital importance to determine whether the cases actually diagnosed as enteric give a correct picture of the incidence of this type of infection among our army in France, or whether there must be added some considerable number of cases which have escaped diagnosis in the early stages and have then gone to swell the large class of undiagnosed pyrexias. A true answer can only be obtained by the close examination of comparatively small samples of cases, and the deduction of a factor which must be applied to the whole mass of undiagnosed pyrexial conditions. Whether it will be possible to arrive at a sound judgment on this matter remains to be seen. This investigation yields a tentative answer which will be confirmed or refuted by .the accumulation of evidence obtained by other workers." " It is probable that taking the whole period, October, 1916, to 1919, between ;5 and 7 per cent. of those cases which were March, invalided to this country from the Western front, suffering or convalescent from undiagnosed febrile conditions, were in reality examples of atypical enteric infection. The percentage of undiagnosed enteric cases was probably higher than this average the earlier part of this period, and lower during the figure during later. This conclusion is based almost entirely on serological and must stand or fall by the reliability of this method evidence, of diagnosis." If these conclusions be sound, there is, I think, an be drawn from them. They would indicate that the incidence of enteric infection was far greater than the figures for the diagnosed cases suggest, while they would emphasise the effect of prophylactic inoculation in transforming a disease of high mortality into a relatively minor infection, and in preventing its epidemic spread. I am, Sir, yours faithfully, W. W. C. TOPLEY. Institute of Pathology, Charing Cross Hospital Medical School, Dec. 14th, 1920.
important lesson to
,
1 Topley, Platts, and Imrie : " A Report on the Probable Proportion of Enteric Infections among Undiagnosed Febrile Cases Invalided from the Western Front since October, 1916." Med. Res. Council, Spec. Rep. Series, No. 48. 1920.