View report page

26
borne outbreak referred to on p. 285, and a somewhat similar recent instance in a London institution
noted on p, 31 of the present Report, in both of which the inoculations preceded the prevalences and the
attacks were almost, or entirely, limited to inoculated persons. In dealing with inoculation carried out
during a prevalence of typhoid fever the fallacy of unequal exposure of inoculated and uninoculated
persons to risk, so carefully examined some years ago (Proc. Roy. Soc. Med. Epidem. Sect. 1914) by
Greenwood and Yule, needs to be borne in mind. This caution would apply to many cases referred to
in the review now under consideration. Furthermore, in several of the outbreaks mentioned the criticism
is inevitable that, perhaps, too much is proved. For example, Peset's description of the epidemic
at Tomares, p. 287, and the account of the influence exerted by inoculation, stage by stage, atVoeuxles-mines,
p. 288, may be mentioned. Some of the American experiences were decidedly unfavourable ;
that of Sawyer, for instance, p. 289; while that of Mackid is inconclusive as no notice is taken of the time
factor, or of dangers lurking in the fallacy above referred to. Descroix (p. 292) points out
that, if inoculation repeated every three years were adopted in France, it would mean a loss of
40,000,000 working days a year, or 600,000,000 francs in salaries. Finally, Rathery and Mathieu (p. 293)
are reported to be frankly antagonistic.
As the subject is being seriously considered in some quarters, it appears desirable to make a few
comments on it from the bacteriological, epidemiological and statistical points of view. In the first place
a sentence from a paper by Lt. Col. Harper maybe quoted ("Lancet," 11th December, 1920, p. 1,190). He
holds that inoculation has been "an important item" in the prevention of typhoid fever on the Western
front; but he very fairly adds, "At the same time it must be admitted that there were other very important
factors at work, viz., the exceptionally capable sanitary administration, the great care taken in the
feeding and comfort of the men, the elaborate arrangements for bacteriological investigation, the prompt
recognition by the regimental officers of the cases of suspect enteric, and the wisdom of the course
adopted early in the War of selecting special hospitals for the investigation and treatment of this disease ;
all these factors had their share in producing such an excellent result." This comprehensive statement
shows a determination to take account of all the pertinent facts, but if so much be admitted an appeal to
inoculation as an important factor is almost rendered unnecessary. The difficulties are not lessened by the
fact that opinion is much divided among bacteriologists with regard to the bearing of recent enquiries
upon the general question. Thus, Lt. Col. Harper belongs to the school of bacteriologists who hold that
the diagnosis of enteric fever has become much complicated since protective inoculation was established,
although he says of typhoid in the inoculated: " There are times when the symptoms are so characteristically
toxic that they resemble the enteric so often seen in the uninoculated." The official figures for
the total incidence of enteric infections in the British Armies in France he gives as 7,423 cases. This
must err considerably on the side of defect, if, as he holds, the disease is to be regarded as being much
modified in the inoculated; indeed, Dr. Topley (" Lancet," 25th December, 1920) considers that " between
5 and 7 per cent, of those cases which were invalided to this country from the western front, suffering, or
convalescent from undiagnosed febrile conditions, were in reality examplesof a typical enteric infection."
Thus, the military case-rate for the Western front is on this showing, at least three or four times as high
as that in the London civilian population for corresponding years.
Dr. Garrow, on the other hand (" Lancet," 30th October, 1920), writing concerning "The myth of
atypical enteric fever," declares that "The influence of anti-enteric inoculation is not to modify enteric
fever, but to prevent it." Dr. Topley criticises this view (loc. cit. and "Lancet," 30th November, 1920).
Dr. Ryle, in the issue of the Lancet last cited supports Dr. Garrow, pointing out "that there occur from
time to time cases of clinically indisputable typhoid fever in which all laboratory efforts fail to achieve
a diagnosis," and contending that "the clinicians rather than the laboratory workers have been at fault
in their too casual acceptance of (laboratory) tests, an insufficient study of their significance, and also
in the needless loss of confidence in their own clinical ability, which the discovery of more minute
scientific methods seems to have engendered."
Dr. Ledingham (" Lancet," 8th January, 1921), while expressing sympathy with Dr. Garrow's main
argument, questions his statement that there is difficulty in recovering enteric bacilli from the blood of
inoculated soldiers (Dr. Garrow subsequently agrees with Dr. Ledingham on this point). Dr. Ledingham
thinks the "fostering of such views gave the impetus to that concentration on agglutination tests which
formed such a feature of enteric diagnosis in France." He quotes Major Vaughan (The Amer. Med.
Assoc., 1920, pp., 1,074, 1,145) to the effect that, "The most striking feature of the disease in the inoculated
is its almost classical resemblance to the old typhoid as we knew it in the unvaccinated." He gives
some very striking "Blood culture results from Mesopotamia."—" Of 139 cases diagnosed by blood
culture, 78 were inoculated men, 28 were returned as not inoculated and 33 were set down as ' no paybook
entry.'" Thus, of the total at least 56.1 per cent, yielding positive blood cultures were definitely
inoculated men; 35 had received T. A. B. vaccine in 1918, the year of the attack, 24 had received their
last dose in 1917, 17 their last dose in 1916, and 2 in 1915, (probably typhoid vaccine only) Dr.
Ledingham appears, moreover, to attach considerable importance to "Besredka's recently promulgated
views on immunity in enteric infections." These "Lancet" letters and articles vividly illumine the
obscurity of the situation from the laboratory point of view, but exigencies of space require that a veil
should now be drawn over this troubled scene.
From the preventive medicine point of view interest mainly turns on the practical question as to
the value of typhoid inoculation. Here, of course, it is necessary to speak with caution for as yet full
information is not obtainable. Attention may, however, profitably be directed to the meagre character
of the statistical records to which much significance has recently been attached. For example, there is
Professor Chauffard's communication (alluded to in the British Medical Journal of 30th April, 1921),
comparing the ages of 11 men attacked in 1912-13, and those of 10 men attacked in 1918-20; and
again somewhat similar figures relating to "a number of localities" in America have been referred to