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The Prophylaxis of Typhoid.
749 infection encountered in the field. Undoubtedly, as an emergency measure, the inoculation of the civil is called for, and population against be to may expected yield valuable results. But difficulties have arisen, as in the epidemic of typhoid which broke out in the Pas de Calais following the drought last summer, when Dr. Louis VAILLANT essayed local prophylactic vaccination. The inhabitants could not readily be persuaded to take the piqure, and many, having experienced the reaction produced by the first dose, declined to submit to a second. Thereupon Dr. VAILLANT proceeded to substitute for the ordinary hypodermic injection the administration of a vaccine combined with bile and given by the mouth. The bile, as BESREDKA has shown, facilitates the absorption of bacterial products from the intestine. Careful inquiry indicated that very slight inconvenience resulted from this method of taking the bacteria : of 396 vaccinated at Bailleul, 15 had slight colic, 5 slight diarrhaea on the first day, 24 headache, and 1 nausea. The typhoid vaccine and bile are taken in pill form on rising in the morning, for three successive days, the material used being triple vaccine, the familiar T.A.B., killed by The results were communicated to the heat. Académie de Medecine, and appear in a recent issue1 Out of a of the Annales de l’Institut Pasteur. total population of 2000, there were 1236 who received vaccine by mouth and 173 vaccinated by hypodermic injection, leaving some 600 who escaped. The results in these three groups are expressed as follows :-
typhoid
THE
LANCET.
LONDON: SZ’ZTRD4Y, APRIL 15, 1922.
The
Prophylaxis
of
Typhoid.
of statistics bearing upon typhoidal disease in the British forces accumulated in the records of our medical services during the war, and is unfortunately not yet available for detailed study. Were this information forthcoming, there is no doubt that it would conclusively and mathematically demonstrate the exact value of antityphoid inoculation, besides throwing light upon a number of collateral problems. In the meantime, it is by the observations of individuals that our knowledge progresses. In the French supplement to the present issue of THE LANCET Prof. CH. ACHARD contributes to some aspects of the problems revolving around typhoid fever. In Great Britain typhoidal disease is at its last gasp. Improved hygiene, albeit acting rather in the dark, had dealt it a severe blow before bacteriology showed the essential method of transmission, and pointed with increasing exactitude the way to collective prophylaxis in ACHARD’S sense. But in France typhoid has proved more stubborn than in this country and-in certain localities, especially the devastated areas in which hygienic measures must be far from perfect, the disease has recently assumed epidemic proportions. Under these circumstances the question has arisen for serious consideration whether individual prophylaxis, in the shape of inoculation, should not be applied broadcast. Influenced no doubt by urgency and economic considerations, the Académie de Medecine has recommended the routine inoculation of adolescents between the ages of 15 and 21 in endemic areas. A second problem, intimately bound up with this decision, for it largely arises therefrom, is that of the permanence of the immunity so produced. If we take the agglutinin content of the blood as evidence of this we find that the protection rapidly declines, but it is becoming more and more widely accepted that the presence of these substances in the blood is no more than an epiphenomenon, and is no index of the resistance of the individual. Prof. ACHARD maintains that the immunity is really durable, and the figures which he quotes, although too few to be statistically reliable, point in this direction ; the incidence of the disease, in the post-war period, has tended in France to fall more on the uninoculated than on the inoculated section of the community. This view may not find support from the experience of medical officers who were in charge of laboratories and infectious hospitals in the late war, whose general experience was that the incidence of typhoidal disease varied directly with the length of time which had elapsed since the patient’s last inoculation. In these cases, moreover, the period which elapsed between the previous inoculation and the onset of the disease was at the most two or three years ; two facts which do not point to any very lasting immunity. It is, however, possible that a relatively small degree of resistance, lingering for a considerable time after inoculation, may suffice to protect against the somewhat slight risks of infection met with in civil life, whilst being quite insufficient to afford protection against the intenser and more massive AN
enormous
mass
1. 1236 vaccinated per os.-Cases, 5morbidity rate, 0’17 per cent. II. 173 vaccinated hypodermically.-Cases, 4;morbidity rate, 2’3 per cent. III. 600 unvaccinated.-Cases, 21 ; morbidity rate, 7’7 per cent.
Twenty-nine cases in Group III., before the vaccibegan, are rightly excluded from the comparison. Of the five cases in Group I., three occurred during vaccination or on the following day, and the remaining two within 10 days. The cases in Group II. occurred between the fifth and twelfth days after nations
vaccination. Prof. ACHARD draws a parallel between immunisation against typhoid and immunisation against smallpox. We do not feel that the comparison is entirely just. Typhoid is a disease conveyed by the excreta, in which the contagium may continue to be discharged for long periods and may live outside the body for no inconsiderable time under favourable conditions. To attack this disease by individual inoculation may be to ward it off for a period and to reduce its incidence in the treated section of the population, but to successfully carry out collective prophylaxis, which is the ideal method, the problem is not one of vaccination ; it is an affair of sewage, water, and milk.
The
Study
of Criminal
Psychology.
A wELCOME revival of interest in the problems of mental disorder and defect amongst all sections of the community is leading to a recognition of the importance of psychopathological factors in the causation of many social evils, with the result that a fresh orientation has been given to the study of crime and punishment Isolated observers had long noted the association of anti-social conduct with mental abnormality, but their insistence was not strong enough appreciably to modify the practice of penal administration. Metaphysician and jurist were authorities by no means disposed to welcome the intrusion of medical science 1 February, 1922, p. 148.
typhoid
THE
LANCET.
LONDON: SZ’ZTRD4Y, APRIL 15, 1922.
The
Prophylaxis
of
Typhoid.
of statistics bearing upon typhoidal disease in the British forces accumulated in the records of our medical services during the war, and is unfortunately not yet available for detailed study. Were this information forthcoming, there is no doubt that it would conclusively and mathematically demonstrate the exact value of antityphoid inoculation, besides throwing light upon a number of collateral problems. In the meantime, it is by the observations of individuals that our knowledge progresses. In the French supplement to the present issue of THE LANCET Prof. CH. ACHARD contributes to some aspects of the problems revolving around typhoid fever. In Great Britain typhoidal disease is at its last gasp. Improved hygiene, albeit acting rather in the dark, had dealt it a severe blow before bacteriology showed the essential method of transmission, and pointed with increasing exactitude the way to collective prophylaxis in ACHARD’S sense. But in France typhoid has proved more stubborn than in this country and-in certain localities, especially the devastated areas in which hygienic measures must be far from perfect, the disease has recently assumed epidemic proportions. Under these circumstances the question has arisen for serious consideration whether individual prophylaxis, in the shape of inoculation, should not be applied broadcast. Influenced no doubt by urgency and economic considerations, the Académie de Medecine has recommended the routine inoculation of adolescents between the ages of 15 and 21 in endemic areas. A second problem, intimately bound up with this decision, for it largely arises therefrom, is that of the permanence of the immunity so produced. If we take the agglutinin content of the blood as evidence of this we find that the protection rapidly declines, but it is becoming more and more widely accepted that the presence of these substances in the blood is no more than an epiphenomenon, and is no index of the resistance of the individual. Prof. ACHARD maintains that the immunity is really durable, and the figures which he quotes, although too few to be statistically reliable, point in this direction ; the incidence of the disease, in the post-war period, has tended in France to fall more on the uninoculated than on the inoculated section of the community. This view may not find support from the experience of medical officers who were in charge of laboratories and infectious hospitals in the late war, whose general experience was that the incidence of typhoidal disease varied directly with the length of time which had elapsed since the patient’s last inoculation. In these cases, moreover, the period which elapsed between the previous inoculation and the onset of the disease was at the most two or three years ; two facts which do not point to any very lasting immunity. It is, however, possible that a relatively small degree of resistance, lingering for a considerable time after inoculation, may suffice to protect against the somewhat slight risks of infection met with in civil life, whilst being quite insufficient to afford protection against the intenser and more massive AN
enormous
mass
1. 1236 vaccinated per os.-Cases, 5morbidity rate, 0’17 per cent. II. 173 vaccinated hypodermically.-Cases, 4;morbidity rate, 2’3 per cent. III. 600 unvaccinated.-Cases, 21 ; morbidity rate, 7’7 per cent.
Twenty-nine cases in Group III., before the vaccibegan, are rightly excluded from the comparison. Of the five cases in Group I., three occurred during vaccination or on the following day, and the remaining two within 10 days. The cases in Group II. occurred between the fifth and twelfth days after nations
vaccination. Prof. ACHARD draws a parallel between immunisation against typhoid and immunisation against smallpox. We do not feel that the comparison is entirely just. Typhoid is a disease conveyed by the excreta, in which the contagium may continue to be discharged for long periods and may live outside the body for no inconsiderable time under favourable conditions. To attack this disease by individual inoculation may be to ward it off for a period and to reduce its incidence in the treated section of the population, but to successfully carry out collective prophylaxis, which is the ideal method, the problem is not one of vaccination ; it is an affair of sewage, water, and milk.
The
Study
of Criminal
Psychology.
A wELCOME revival of interest in the problems of mental disorder and defect amongst all sections of the community is leading to a recognition of the importance of psychopathological factors in the causation of many social evils, with the result that a fresh orientation has been given to the study of crime and punishment Isolated observers had long noted the association of anti-social conduct with mental abnormality, but their insistence was not strong enough appreciably to modify the practice of penal administration. Metaphysician and jurist were authorities by no means disposed to welcome the intrusion of medical science 1 February, 1922, p. 148.