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THE LANCET.

LONDON: SATURDAY, DECEMBER 10, 1921.

Old and New Methods of DiphtheriaPrevention.

THE report on diphtheria, made to the Ministry ofHealth by Dr. S. MONCKTON COPEMAN, published lastweek, should give an impetus to the greater use inthis country both of the Schick reaction as a meansof determining susceptibility to the disease, and oftoxin-antitoxin mixture as a means of conferringactive immunity on those who are found to be suscep-tible. From the time of SCHmCK’s first publication in1913 onwards the nature of this simple test has beenfrequently described in medical literature, and thecharacter of positive and " pseudo

" reactionsobtained to it have been illustrated. The extensiveuse made of this test, and of active immunisationmethods, in certain American cities, especially NewYork, is also common knowledge. When all duereservations are made, it seems certain that once the

technique of this little test has been mastered, andexperience has been gained in judging the reactions,(especially if a control test with heated toxin solutionis performed at the same time on the opposite arm;)the distinction of the positive response presents littledifficulty, when it can be asserted with considerableconfidence that on exposure to infection diphtheriawill only occur among the positive reactors.This separation of susceptibles in itself is a valuable

aid to preventive measures in times of epidemicdiphtheria. It is still more valuable as an index to thosemembers of the community at risk, who should beadvised to receive active immunising treatment bytoxin-antitoxin mixture, in the anticipation that theywill obtain an effective immunity which is likely to lastfor several years. In this country, partly because othermeans of dealing with the spread of diphtheria are sowell established, and partly through the absence ofany supply of the necessary materials by public healthauthorities, the Schick and associated methods havebeen very little used in practice. Dr. COPEMAN’S

presentment of the facts is derived mainly from PARK,ZINGHER, and others who have,-secured the adoptionof these methods on a most extensive scale in theschools of New York, as well as among the generalpopulation of that city. In Great Britain the Schicktest has been applied, though only on an experimentalscale, at a few infectious diseases hospitals, notablythose in Edinburgh and Manchester. Dr. COPEMAN’Sown experience has been limited to trials of the methodon a small scale, first in an institution in Bristol, andlater at the Mitcham Schools of the Holborn Union.The results of these trials, which he made with theassistance of several distinguished fellow-workers, andwith standardised toxin-antitoxin mixtures preparedby Dr. R. A. O’BRIEN of the Wellcome Laboratories,appears to have been generally satisfactory. In theMitcham schools, all of 329 children, ranging in agefrom 3 to 14 years, were submitted to the Schick test,and 98 afforded a positive reaction. All the reactorswere immunised by means of at least three separateinoculations of toxin-antitoxin at intervals of four toseven days in doses of 0.05 c.cm., 0.25 c.cm., and1 c.cm. In three only was the reaction following the

inoculation even of sufficient severity to require a

day’s stay in bed. Of eight adults inoculated withsimilar doses, none were off duty at any time, althoughone suffered from malaise and soreness of the arm fora couple of days. According to the view expressed inthis report, the evidence of the effectiveness of theSchick method combined with active immunisation isnow sufficient to make its adoption desirable in specialcases. A chief instance is that of nurses and others whocome into close contact with diphtheria infection.Another is the systematic use of the method inresidential schools and similar limited communities.Further than this, there is the not infrequent case ofparents who are specially anxious to avoid all possiblerisk of diphtheria infection for their children, and whoare anxious and ready to accept any prophylacticmethod which can be recommended to them with con-fidence. A more difficult question is raised when it isasked whether the general application of this measureof prevention, as adopted in New York, should berecommended for English communities. The obstacleswhich would have to be met, before wholesale testingand inoculation could be undertaken at our elementaryschools, and among the population generally, are

obvious and somewhat formidable. In a note, addressedto Sir GEORGE NEWMAN and forming a preface to Dr.CoPEMAN’s report, Dr. G. S. BUCHANAN expresses theopinion that it would be premature to advise such asystem of general immunisation in this country.Before this could be done, it would be necessary notonly to have further and longer experience of the NewYork results, but also to consider whether equallygood results cannot be achieved by the customarymeasures of diphtheria prevention which we adopt,and more particularly by improved methods based onthe same principles. It is clear that in some respectsour traditional means of dealing with diphtheriaprevalence need to be revi-od.The principal directions in which revision is neces-

sary will be found in Dr. BuCHANAN’S observations,given elsewhere in our present issue, which raise

practical considerations of considerable import-ance. Measures of prevention in regard to

diphtheria carriers ought, in view of present know-ledge, to be restricted, if it can be shown to bepossible, to those carriers whose diphtheria bacilliare demonstrated to be virulent. The practicabilityof applying this principle depends largely on the

development of laboratory methods recently proposed,by which the virulence of a number of separate culturescan be tested simultaneously on the same experi-mental animal. The restriction of preventive measuresto virulent cases would, of course, permit a verydesirable economy in time and in money when dealingwith diphtheria outbreaks. Another important econo-mical consideration is raised in the portion ot the reportwhich insists that there is no good legal or practicalground for notifying the " bacteriological " carrier,otherwise healthy, as a case of diphtheria, or for

removing such a carrier to an isolation ho.°pital-often to the exclusion of cases requiring treatment.The warning given against waiting for bacteriologica!confirmation before giving antitoxin in cases alreadyclinically recognised as diphtheria deserves specialattention, as also do the limitations of routine swabbingat schools and hospitals. It is evident that methodsof prevention based on the detection of infective casesand carriers should not be discarded in favour of thenew systems of prophylaxis until further efforts havebeen made to improve on them in the light of newerknowledge of the carrier condition and of virulencetests. This can only be done by careful collection andstudy of the experience, past and future, of public

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health officers, medical officers of isolation hospitalsand schools, with the closest possible association ofthe bacteriological laboratory in their investigations.It is satisfactory to note that the Ministry of Healthare continuing to obtain the facts from all these

sources, as well as from special research being con-ducted by the Medical Research Council, in the hopethat before long it will be possible to obtain scientificauthority for a code for the prevention of the spreadof diphtheria as definite as that which we now possessin the cases of enteric fever and small-pox.

The Therapeutic Possibilities ofB-Vitamin.

THE absence of t3-vitamin from food has hithertobeen associated mainly with those severe symptomscollectively grouped together as beri-beri : hence thisvitamin is often referred to as the anti-neuriticfactor. But though these manifestations are the finalresult of the long-continued consumption of foodentirely lacking, or containing a little but not enoughof, this vitamin, the earlier signs appear to be of evengreater importance. MCCARRISON, who has studiedthis aspect of the disease with such care in animals andman, considers that the earlier symptoms are referableto the digestive and endocrine systems, and only thelater ones to the nervous system. In the early stageshe has recorded loss of appetite, indigestion, flatulence,abdominal pain due to gaseous distension of the hollowviscera, headache, giddiness, weakness, coldness,breathlessness; and at a later stage chronic con-

stipation, colitis, appendicitis, intussusception, stasis,and gastro-duodenal ulcers. Post-mortem examinationshowed atrophy of thymus, pancreas, spleen, and allendocrine organs except the adrenals, which wereenlarged. CRAMER, DREW, and MOTTRAM record inour present issue (p. 1202) that rats fed on a dietdeficient in B-vitamin showed a shrinkage of thymusand spleen, almost complete disappearance of

Peyer’s patches and lymphoid tissue in general, and adiminution of small lymphocytes in the blood. Astate of marasmus is associated with this atrophy oflymphoid tissue and is apparently the specific effect Iof the absence of B-vitamin. In concluding from theirobservations that B-vitamin is not necessary for thelife of each individual cell, and that its presence is

necessary solely for the normal functioning of lymphoidtissue, the authors enter upon more debatableground. If the effect of absence of B-vitamin werelimited to the atrophy of lymphoid tissue and pro-duction of marasmus, such a conclusion might be

justifiable, but their theory will scarcely account forthe complexity of symptoms in beri-beri. Thearticle by Dr. SAMSON WRIGHT, on p. 1208, drawsattention to the loss of appetite of animals fed on adiet deficient in B-vitamin, the quantity eaten beingdependent on the apparent quantity of B-factor in thefood.

Of the three vitamins, the B-factor seems most closelyconnected with metabolism, growth, and health.Several workers have observed a connexion betweenfood assimilation and the amount of B-vitamin inthe food, and it is surprising that while each ofthe three vitamins have long been used as specificsfor certain diseases, the general therapeutic andtonic possibilities of B-vitamin have not beenfurther explored. This subject offers an almostvirgin field to the general practitioner anxious to dosome useful clinical research, and we commend to hisattention the therapeutic considerations advanced byDrs. CRAMER, DREW, and MoTTRAM as well as the

suggestions of Dr. SAMSON WRIGHT. Carbohydrate andfat metabolism seem dependent upon a proportionateamount of B-factor per calorie ingested. This connexionsuggests the administration of B-vitamin in cases ofdiabetes to assist the utilisation of sugar. The additionof cod-liver oil or butt3r (fats rich in A-vitamin) to adiet deficient in B -vitamin has been shown to cause lossof weight and ill-health, while an increase in amountof B-vitamin led to assimilation of the fat with renewedhealth and growth. Cases of marasmus in infants,which had failed to put on weight by the usual treat-ment, began to grow directly they were given extraB-vitamin. As long ago as 1917 A. F. HESS 1 foundthat although yeast, which is rich in B-vitamin,apparently possessed little or no value as an

antiscorbutic, it proved an excellent stimulant of

growth in infants ; he showed graphs of infantsof under 1 year, 12, and 2 years old who hadmaintained an almost constant weight for weeks ormonths in spite of various changes in diet, andshowed an immediate and continuous rise after theadministration of autolysed yeast. In some cases theappetite was stimulated, but in others there was aprompt response though the total food intake wasnot increased. That the yeast had a favourableeffect on the digestive processes was shown not onlyby the increase in appetite, but by the improvedcharacter of the stools.The chief source of B-vitamin in our food is the seeds

of cereals and other plants, but the factor is removedfrom cereal seeds in the process of milling. Sugar,sago, and other farinaceous products are lacking inB-factor, meat and fish are poor, offal and eggs incomparison rich. Vegetables and milk contain smallamounts. The quantity in these foodstuffs is scarcelysufficient to balance the large carbohydrate consump-tion of white flour in our diet, unless eggs, fruits, andvegetables are eaten in great quantities. The productsrichest in B-vitamin are the germ of cereals andyeast. Germ as such is not consumed by humans(except in wholemeal bread) and the yeast usedin baking bread is not sufficient. Yeast containsB-vitamin in great concentration, and palatablepreparations made therefrom can compensate forthe lack of B-vitamin in other foods. No ill-effects have been ascribed to too great a consumptionof foods rich in B-vitamin, and it is likely thatcertain cases of vague ill-health would be improvedby the consumption of additional quantities ofB-vitamin. - There is here a promising field forclinical research.

The Teaching of Practical

Midwifery.AT the recent meeting of the General Medical

Council the Report of the Examination Committee onthe latest series of inspections of the qualifying exami-nations furnished material for an important debate,and will have given rise to much reflection in the Councilas well as outside. The inspectors for medicine andfor surgery reported that the examinations held by23 of the bodies empowered to grant legal qualifica-tions were satisfactory, but the inspector for midwiferyand gynaecology, Sir WILLIAM SMYLY, had no such taleto tell. There is no part of the practitioner’s workso anxious and so responsible as his work as obstet-rician, and in no department of his duties are skilland watchfulness so repaid in the saving of life, inthe prevention of sickness and deformity, and-a verypractical addition-in the earning of unstinted

1 American Journal of Diseases of Children, 1917, xiii., 98.