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SOME FURTHER STATISTICS REGARDING THE EFFECT OF INOCULATION AGAINST TYPHOID FEVER IN SOUTH AFRICA,
426 of the
worm
into the
cytoplasm
of the host to absorb nutri-
and, indeed, the vesicle gradually fills with a clear, transparent fluid. Besides, on the ninth day or thereabouts ment
law referred to was probably that of age and susceptibility. He thought it probable that the inoculated would be found to be younger men than the non-inoculated and that the higher incidence among the former after the six months of protection afforded by inoculation had passed was in all likelihood due to the re-assertion of their greater susceptibility on account of their comparative youth. I had not recorded the ages of the 250 officers who furnished the statistics and I accordingly commenced a new series of observations with a view to ascertain what truth there was in Piofessor Wright’s suggestion. The following figures are the result of this inquiry. Table I. shows that the average age of the inoculated was 25’4 years and that of the noninoculated was 30’6years, a difference of five years. The incidence of typhoid fever among the former was 33’3 per cent. and among the latter 32 9 per cent.
the chyliferous intestine becomes connected with the posterior intestine and the protruding part of the latter opens to form the anus. Thenceforth the filaria feeds by the mouth. Dr. Noe has observed that the ularias undergo at times a brown degeneration within the Malpighian tubes of their host and, true to the traditions of the Roman school, he believes this degeneration to be a retrogressive process of the parasite. This so-called brown degeneration begins by scattered brown spots which under a strong magnifying power have a lenticular shape. The spots gradually increase in number and coalesce into large dark-brown patches. These brown bodies may appear on a few or on all the filariæ contained in one or in all of the Malpighian tubes of a " mosquito. They are no other than the "black spores" TABLE I.-Showing the Average Age of the Inoculated and. described first by Major Ross in connexion with the hasmNon -inoc1tlat ed. amœbidæ. I believe that they represent a parasitic infection I comparable to the pebrine disease of silk worms. Dr. Noe closes his paper with a most extraordinary remark. He recognises that the prodigious fertility of filaria immitis is an admirable adaptation for the perpetuation of the species, but he explains its operation in a way which seems to me to be far more original than reasonable He says that the mosquitoes become so easily infected that if numbers of them did not die the canine species would soon become totally extinct and with the disappearance of dogs the filariæ would necessarily also disappear ; therefore, to avoid such a disaster the filari2e have excogitated the admirable means of killing off their necessary intermediary hosts by a prodigious fertility and consequent heavy infection. Dr. Noe explains the passage of the filaria from definitive to intermediary and The figures in Table I. show a distinct advantage in from intermediary to definitive hosts in a totally passive way favour of a single inoculation, but they indicate a strong and I will not ask him why other niarise develop in other susceptibility to enteric fever among those who were of the instead like of his filaria mosquito inoculated twice. In this series 10 out of 13 officers who parts gravitating, immitis, first into the Malpighian tubes when the mosquito were inoculated twice on the outward passage contracted sits up after its meal, and then into the labium when the typhoid fever after disembarkation in South Africa. In my latter comes down again head foremost to draw blood, but I first series the proportion attacked was smaller, two in 10. feel that I must protest against the stigma of suicidal mania Taking the two series together it will be found that of 23 which he casts on the worm, forgetting the universal sig- double inoculations 12 were infected, or over 50 per cent., as nificancy of an enormous fertility which is common to against 33 per cent. amoog the non-inoculated. I do not numberless species, and forgetting that the domestic dog think that a difference of age amounting to five years would may possibly not be the only definitive host of filaria immitis account for this greater incidence ; and it is possible that and that filaria immitis, although widely distributed, is the double inoculation is excessive and diminishes the strictly limited to certain swampy stations. resisting power of the blood to infection. The incidence among those twice inoculated is just double that among the once inoculated, and such a result would not be in discord with of Professor Wright’s more recent experimental SOME FURTHER STATISTICS REGARDING work. some THE EFFECT OF INOCULATION In the following tables (Tables II., III., IV., and V.) the incidence in relation to age is shown in detail. They show AGAINST TYPHOID FEVER that 60 per cent. of the inoculated were under 26 years of IN SOUTH age, against 22 per cent. among the non-inoculated. The incidence at this age among the non-inoculated was 63’4 per WITH SPECIAL REGARD TO THE QUESTION OF AGE. cent. ; among those inoculated once 27’8 per cent. ; and BY ALEXANDER CROMBIE, M.D EDIN., This gives a among those inoculated twice 71’4 per cent. difference of 35 per cent. in favour of a single inoculation LIEUTENANT-COLONEL, I.M.S. (RETIRED). at this age, which must be regarded as a very substantial of 26 and 35 years the number of IN THE LANCET of May 3rd, 1902, at p. 1241, will be gain. Between the inoculated constituted 31 per cent. of the total inoculated, found the statistics of 250 officers invalided from South 50 per cent. among the non-inoculated. At these Africa for various causes. These figures showed a higher against ages the incidence among 42 non-inoculated was 31 per cent. ; percentage incidence of typhoid fever among the inoculated among 27 inoculated once 22 per cent. ; and among five (28’ 5) than among the non-inoculated (22’0), and it was inoculated twice 80 per cent. Here there was a gain of 9 pointed out that this might be due to a higher rate of re- per cent. among those inoculated once. coveries among the inoculated. I do not propose to discuss TABLE 11. --Inoculated Once. the figures which might be adduced in support or otherwise of this opinion. My figures also showed that the average date of attack aftrr disembarkation in South Africa was shorter among the inoculated (9’ 4 months) than among the non inoculated (10’3 months), but that the non-inoculated were more susceptible during the firnt five months after di-embarkation than the inoculated. The inference to be drawn from the-e figure- was that inoculation conferred a certain measure of protection for a period of about six After that period the inoculated appeared to suffer months more than the nou inoculated. I hinted that these differences in licated the operation of some law affecting the figures. The publication of these statistics led to a correpondence with Professor Wright of Netley who suggested that the
AFRICA,
ages
427 the incidence in this class being 27 per cent. against 51 per among those not inoculated. Beyond the age of 30 years the position is reversed and the advantage is with the non-inoculated, the incidence among them being then only 14 3 per cent., against 27 4 per cent., among thot-e inoculated once. These figures would seem to suggest that as the period of natural susceptibility to the disease is passing away inoculation is to be avoided as likely to increase the liability to infection. The whole question of immunity, and the effect of inoculation on immunity, is evidently and admittedly a most difficult and complicated one. I am glad, however, to be able to point out by these statistics the unmistakeable evidence which they afford of the clear and substantial advantage a single inoculation gives to the young soldier under the age of 30 years, and especially at the age when his susceptibility to the infection is greatest. With regard to the period which elapsed between disembarkation in South Africa and the attack the average for those not inoculated was 14 4 months, for those inoculated once it was 11-8 months, for those inoculated twice it was 7.7months, and for those who had had a previous attack of enteric fever 11 months. These periods bear the same relation to each other as in my previous series of cases. The advantage of the non-inoculated in this respect is doubtless to be accounted for by their greater average age and consequent lower susceptibility. The early attack of those inoculated twice is corroborative of the opinion expressed above, that a double inoculation increases the suscepti-
TABLE III-Inoculated T7vice.
cent-
infection. Bickenhall-mansions, W.
bility to
THE TREATMENT OF APPENDICITIS. BY JOHN SENIOR MEDICAL
O’CONOR, M.A., M.D. DUB.,
OFFICER,
BRITISH
HOSPITAL,
BUENOS AYRES.
IT may be of some interest if I endeavour to report the conclusions derived from 140 operations for appendicitis. In order that no misunderstanding may arise I will commence by quoting an extract from Sir Frederick Treves’s excellent work on " Surgical Applied Anatomy," which I consider fully illustrates the complex anatomical nature Above the age of 35 years the advantage was in favour of of the infection and the difficulties which must necessarily those not inoculated, of whom 28 per cent. were included in attend clinical diagnosis. " The mesentery of the appendix this section, against 9 per cent. of the inoculated. The which contains an artery derived from the ileo colic, may be incidence of enteric fever at this period of life was 12’5 per cent. for the 24 non-inoculated, 37’ 5 per cent. for the eight so short as to produce obstructive kinks in the appendix. inoculated once, and 100 per cent. for the one individual The mucous lining is so crowded with solitary lymphoid inoculated twice-an advantage of 25 per cent. in favour of follicles as almost to occlude its lumen. In some forms of non-inoculation over one inoculation. I am not in a position appendicitis these follicles are involved. They are surto offer any explanation of this remarkable outcome of my rounded by lymph spaces, from which vessels pass to the statistics. lymph glands in the mesentery and others pass upwards For the more ready perception of the effect of inoculation behind the ascending colon (Lockwood). It is probably at different ages I append in Table VI. the differences through these latter vessels that infection pafses from the observed in the incidence of the disease in the different appendix and gives rise to abscesses in the subdiaphragmclasses, taking that among the non-inoculated as a standard atic region. The muscular coat of the appendix is scanty at each quinquennial period. and through breaks in it the submucous tissue communicates with the subserous. Inflammation of the mucous TABLE VI. membrane may, therefore, spread without hindrance to the peritoneum."At present there are three operative procedures in vogue for purulent appendicitis- cosliotomy and drainage without subsequent removal of the appendix ; coeliotomy with drainage and secondary appendicectomy; and coeliotomy, removal of pus, separation of adhesions, and appendicectomy at the same time. The advocates of the firstmethod have not as yet got rid of the erroneous idea that in the wreck of matter attending abscess formation destruction of the Personally I never appendix not infrequently occurs. and I have had ample believed in such a doctrine practical proof that the appendix never completely disappears without the help of a surgical instrument, but I have frequently operated on cases in which the organ appeared to be transformed into a kind of fibrous cord, which, by the way, was invariably adherent to something and caused the patients continual These tables show that the period of greatest susceptibility indigestive worry, which can be explained by its tent-rope to enteric fever is from 20 to 25 years of age. This was true action on a distensile and sluggish cæcum. for the inoculated as well as the non-inoculated, but it was On three occasions I have had to remove the appendix precisely at this period that the evidence of the protective luring a recurrent purulent attack in patients who had effect of inoculation was most marked. Up to the age of ncision and drainage performed by other surgeons years 30 years the advantage of a single inoculation is distinct, before and in each instance I found the appendix entire. In
practical
I
worm
into the
cytoplasm
of the host to absorb nutri-
and, indeed, the vesicle gradually fills with a clear, transparent fluid. Besides, on the ninth day or thereabouts ment
law referred to was probably that of age and susceptibility. He thought it probable that the inoculated would be found to be younger men than the non-inoculated and that the higher incidence among the former after the six months of protection afforded by inoculation had passed was in all likelihood due to the re-assertion of their greater susceptibility on account of their comparative youth. I had not recorded the ages of the 250 officers who furnished the statistics and I accordingly commenced a new series of observations with a view to ascertain what truth there was in Piofessor Wright’s suggestion. The following figures are the result of this inquiry. Table I. shows that the average age of the inoculated was 25’4 years and that of the noninoculated was 30’6years, a difference of five years. The incidence of typhoid fever among the former was 33’3 per cent. and among the latter 32 9 per cent.
the chyliferous intestine becomes connected with the posterior intestine and the protruding part of the latter opens to form the anus. Thenceforth the filaria feeds by the mouth. Dr. Noe has observed that the ularias undergo at times a brown degeneration within the Malpighian tubes of their host and, true to the traditions of the Roman school, he believes this degeneration to be a retrogressive process of the parasite. This so-called brown degeneration begins by scattered brown spots which under a strong magnifying power have a lenticular shape. The spots gradually increase in number and coalesce into large dark-brown patches. These brown bodies may appear on a few or on all the filariæ contained in one or in all of the Malpighian tubes of a " mosquito. They are no other than the "black spores" TABLE I.-Showing the Average Age of the Inoculated and. described first by Major Ross in connexion with the hasmNon -inoc1tlat ed. amœbidæ. I believe that they represent a parasitic infection I comparable to the pebrine disease of silk worms. Dr. Noe closes his paper with a most extraordinary remark. He recognises that the prodigious fertility of filaria immitis is an admirable adaptation for the perpetuation of the species, but he explains its operation in a way which seems to me to be far more original than reasonable He says that the mosquitoes become so easily infected that if numbers of them did not die the canine species would soon become totally extinct and with the disappearance of dogs the filariæ would necessarily also disappear ; therefore, to avoid such a disaster the filari2e have excogitated the admirable means of killing off their necessary intermediary hosts by a prodigious fertility and consequent heavy infection. Dr. Noe explains the passage of the filaria from definitive to intermediary and The figures in Table I. show a distinct advantage in from intermediary to definitive hosts in a totally passive way favour of a single inoculation, but they indicate a strong and I will not ask him why other niarise develop in other susceptibility to enteric fever among those who were of the instead like of his filaria mosquito inoculated twice. In this series 10 out of 13 officers who parts gravitating, immitis, first into the Malpighian tubes when the mosquito were inoculated twice on the outward passage contracted sits up after its meal, and then into the labium when the typhoid fever after disembarkation in South Africa. In my latter comes down again head foremost to draw blood, but I first series the proportion attacked was smaller, two in 10. feel that I must protest against the stigma of suicidal mania Taking the two series together it will be found that of 23 which he casts on the worm, forgetting the universal sig- double inoculations 12 were infected, or over 50 per cent., as nificancy of an enormous fertility which is common to against 33 per cent. amoog the non-inoculated. I do not numberless species, and forgetting that the domestic dog think that a difference of age amounting to five years would may possibly not be the only definitive host of filaria immitis account for this greater incidence ; and it is possible that and that filaria immitis, although widely distributed, is the double inoculation is excessive and diminishes the strictly limited to certain swampy stations. resisting power of the blood to infection. The incidence among those twice inoculated is just double that among the once inoculated, and such a result would not be in discord with of Professor Wright’s more recent experimental SOME FURTHER STATISTICS REGARDING work. some THE EFFECT OF INOCULATION In the following tables (Tables II., III., IV., and V.) the incidence in relation to age is shown in detail. They show AGAINST TYPHOID FEVER that 60 per cent. of the inoculated were under 26 years of IN SOUTH age, against 22 per cent. among the non-inoculated. The incidence at this age among the non-inoculated was 63’4 per WITH SPECIAL REGARD TO THE QUESTION OF AGE. cent. ; among those inoculated once 27’8 per cent. ; and BY ALEXANDER CROMBIE, M.D EDIN., This gives a among those inoculated twice 71’4 per cent. difference of 35 per cent. in favour of a single inoculation LIEUTENANT-COLONEL, I.M.S. (RETIRED). at this age, which must be regarded as a very substantial of 26 and 35 years the number of IN THE LANCET of May 3rd, 1902, at p. 1241, will be gain. Between the inoculated constituted 31 per cent. of the total inoculated, found the statistics of 250 officers invalided from South 50 per cent. among the non-inoculated. At these Africa for various causes. These figures showed a higher against ages the incidence among 42 non-inoculated was 31 per cent. ; percentage incidence of typhoid fever among the inoculated among 27 inoculated once 22 per cent. ; and among five (28’ 5) than among the non-inoculated (22’0), and it was inoculated twice 80 per cent. Here there was a gain of 9 pointed out that this might be due to a higher rate of re- per cent. among those inoculated once. coveries among the inoculated. I do not propose to discuss TABLE 11. --Inoculated Once. the figures which might be adduced in support or otherwise of this opinion. My figures also showed that the average date of attack aftrr disembarkation in South Africa was shorter among the inoculated (9’ 4 months) than among the non inoculated (10’3 months), but that the non-inoculated were more susceptible during the firnt five months after di-embarkation than the inoculated. The inference to be drawn from the-e figure- was that inoculation conferred a certain measure of protection for a period of about six After that period the inoculated appeared to suffer months more than the nou inoculated. I hinted that these differences in licated the operation of some law affecting the figures. The publication of these statistics led to a correpondence with Professor Wright of Netley who suggested that the
AFRICA,
ages
427 the incidence in this class being 27 per cent. against 51 per among those not inoculated. Beyond the age of 30 years the position is reversed and the advantage is with the non-inoculated, the incidence among them being then only 14 3 per cent., against 27 4 per cent., among thot-e inoculated once. These figures would seem to suggest that as the period of natural susceptibility to the disease is passing away inoculation is to be avoided as likely to increase the liability to infection. The whole question of immunity, and the effect of inoculation on immunity, is evidently and admittedly a most difficult and complicated one. I am glad, however, to be able to point out by these statistics the unmistakeable evidence which they afford of the clear and substantial advantage a single inoculation gives to the young soldier under the age of 30 years, and especially at the age when his susceptibility to the infection is greatest. With regard to the period which elapsed between disembarkation in South Africa and the attack the average for those not inoculated was 14 4 months, for those inoculated once it was 11-8 months, for those inoculated twice it was 7.7months, and for those who had had a previous attack of enteric fever 11 months. These periods bear the same relation to each other as in my previous series of cases. The advantage of the non-inoculated in this respect is doubtless to be accounted for by their greater average age and consequent lower susceptibility. The early attack of those inoculated twice is corroborative of the opinion expressed above, that a double inoculation increases the suscepti-
TABLE III-Inoculated T7vice.
cent-
infection. Bickenhall-mansions, W.
bility to
THE TREATMENT OF APPENDICITIS. BY JOHN SENIOR MEDICAL
O’CONOR, M.A., M.D. DUB.,
OFFICER,
BRITISH
HOSPITAL,
BUENOS AYRES.
IT may be of some interest if I endeavour to report the conclusions derived from 140 operations for appendicitis. In order that no misunderstanding may arise I will commence by quoting an extract from Sir Frederick Treves’s excellent work on " Surgical Applied Anatomy," which I consider fully illustrates the complex anatomical nature Above the age of 35 years the advantage was in favour of of the infection and the difficulties which must necessarily those not inoculated, of whom 28 per cent. were included in attend clinical diagnosis. " The mesentery of the appendix this section, against 9 per cent. of the inoculated. The which contains an artery derived from the ileo colic, may be incidence of enteric fever at this period of life was 12’5 per cent. for the 24 non-inoculated, 37’ 5 per cent. for the eight so short as to produce obstructive kinks in the appendix. inoculated once, and 100 per cent. for the one individual The mucous lining is so crowded with solitary lymphoid inoculated twice-an advantage of 25 per cent. in favour of follicles as almost to occlude its lumen. In some forms of non-inoculation over one inoculation. I am not in a position appendicitis these follicles are involved. They are surto offer any explanation of this remarkable outcome of my rounded by lymph spaces, from which vessels pass to the statistics. lymph glands in the mesentery and others pass upwards For the more ready perception of the effect of inoculation behind the ascending colon (Lockwood). It is probably at different ages I append in Table VI. the differences through these latter vessels that infection pafses from the observed in the incidence of the disease in the different appendix and gives rise to abscesses in the subdiaphragmclasses, taking that among the non-inoculated as a standard atic region. The muscular coat of the appendix is scanty at each quinquennial period. and through breaks in it the submucous tissue communicates with the subserous. Inflammation of the mucous TABLE VI. membrane may, therefore, spread without hindrance to the peritoneum."At present there are three operative procedures in vogue for purulent appendicitis- cosliotomy and drainage without subsequent removal of the appendix ; coeliotomy with drainage and secondary appendicectomy; and coeliotomy, removal of pus, separation of adhesions, and appendicectomy at the same time. The advocates of the firstmethod have not as yet got rid of the erroneous idea that in the wreck of matter attending abscess formation destruction of the Personally I never appendix not infrequently occurs. and I have had ample believed in such a doctrine practical proof that the appendix never completely disappears without the help of a surgical instrument, but I have frequently operated on cases in which the organ appeared to be transformed into a kind of fibrous cord, which, by the way, was invariably adherent to something and caused the patients continual These tables show that the period of greatest susceptibility indigestive worry, which can be explained by its tent-rope to enteric fever is from 20 to 25 years of age. This was true action on a distensile and sluggish cæcum. for the inoculated as well as the non-inoculated, but it was On three occasions I have had to remove the appendix precisely at this period that the evidence of the protective luring a recurrent purulent attack in patients who had effect of inoculation was most marked. Up to the age of ncision and drainage performed by other surgeons years 30 years the advantage of a single inoculation is distinct, before and in each instance I found the appendix entire. In
practical
I