(table) also supports the views on the pathogenesis of typhoid fever being discussed in this paper. The Louisiana outbreak8 is unusual; it was similar to the Abyad outbreak" in being caused by a phage-type El organism, in having an attack rate of about 35%, and in showing a bimodal distribution of the incubation periods, but its modes of the case-onset pattern are greater-that is, 18 and 29 days after infection. In this connection it is interesting to note that in the experimental infections described by Woodward and Hornick (figure) there are modes at 7 and 21 days as well as at 28 days. Moreover, there is a suggestion ofa third mode in the Abyad outbreak at 30 days. It would seem then that an infecting dose of an appropriate size and virulence can produce an outbreak with 2 or even 3 modes in the case-onset pattern because groups within the
population exposed to the infecting organism differ genetically in their susceptibility to infection. OUTBREAKS OF ENTERIC FEVER IN THE MIDDLE EAST
Further information on the case-onset pattern in foodborne outbreaks emerges from my work in 1950 and 1951 when, as enteric officer to the Middle East Land Forces, I was responsible for the laboratory work on outbreaks of enteric fever (typhoid and the paratyphoids) in the Army and R.A.F. in the Middle East. The forces had all received T.A.B. vaccine. The prevalence of enteric carriers among the Egyptian food handlers working for the forces was high and the water supplies were very carefully controlled, and chlorinated. The large typhoid outbreak at Abyad has been referred to. 10 There were also several smaller outbreaks, each caused by one phage type (either Salmonella typhi or Salm. paratyphi B) and affecting men either on the same unit or widely distributed throughout the Canal Zone. I paid particular attention to the dates of onset of illness and the duration of each outbreak-that is, the interval between the date of onset of the first and last cases. Duration had to be measured in this way and not as the interval between the first case and the mode of the frequency distribution because some of the outbreaks were too small to allow the recognition of a mode. The striking observation was that all outbreaks lasted less than 16 days. My view then2’ was that "Most of the outbreaks studied among British troops in the Suez Canal Zone during 1950 and 1951 were quite unlike those traced to a persistent carrier in the camp kitchen. The outbreaks were of short duration; apart from secondary cases, all patients became ill within 16 days. Such outbreaks ceased spontaneously and were probably due to a single infected article of food". All these outbreaks presumably were due to food contaminated by a large dose of organisms causing a breakdown in host resistance during the early net growth phase of the organism. Not all sources of contaminated food were identified, and the outbreaks which were geographically widespread were probably due to extensive distribution of a common food item. The narrow-case-onset curve again supports the suggestion that host resistance to enteric infection in the early net growth phase is dependent on a small number of genes, possibly a single gene. The practical value of the 16-day interval was that it indicated a single item of infected food or single episode of infection: the occurrence of cases with onsets beyond 16 days indicates a continuing source of infection. I thank Dr W. E. Woodward for data on incubation periods of typhoid fever in the experiments he conducted with Dr R. B. Hornick.
Gay FP Typhoid fever: considered as a problem of scientific medicine. New York Macmillan Company, 1918 2. Hormaeche CE Immunity mechanisms m salmonella infections. Ph.D thesis. University of Cambridge, 1976. 3. Hormaeche CE. Natural resistance to Salmonella typhimurium in different inbred mouse strains. Immunology 1979a; 37: 311-18. 4. Hormaeche CE. Genetics of natural resistance to salmonellae in mice. Immunolog. 1979b; 37: 319-27 5. Woodward WE, Hornick RB. Induced typhoid fever and experimental typhoid vaccines: a study of 1886 volunteers. Rev Infect Dis (in press). 6 Ash I, McKendrick GDW, Robertson MH, Hughes HL Outbreak of typhoid fever connected with corned beef. Br Med J 1964; i: 1474-78 7 Bradley WH, Wilson Evans L, Taylor I. A hospital outbreak of typhoid fever J Hyg (Lond) 1951; 49: 324-34. 8. Caraway CT, Bruce JM. Typhoid fever epidemic following a wedding reception Publ Hlth Rep 1961; 76: 427-30. 9 Couper WRM, Newell KW, Payne DJH An outbreak of typhoid fever associated with canned ox-tongue Lancet 1956; i: 1057-59. 10 Marmion DE, Naylor GRE, Stewart IO. Second attacks of typhoid fevee. J Hyg(Lond) 1953; 51: 260-67. 1 1. Milne D, Borthwick AM, Howie JW, Pike G, Semple AB. The Aberdeen typhoid outbreak 1964 report ofthe departmental committee of enquiry. Edinburgh. H M Stationery Office, 1964. 12. Moore WB. Typhoid fever, with particular reference to the Crowthorne epidemic, 1949. J Roy San Inst 1950; 70: 93-101. 13. Ramsey GH, Benning CH, Orr PF. An epidemic of typhoid fever following achurch dinner Am J Publ Hlth 1926; 16: 1011-16. 14. Sawyer WA. Ninety-three persons infected by a typhoid carrier at a public dinner. JAMA 1914; 63: 1537-42. 15. Taylor A Jr, Santiago A, Gonzalez-Cortes A, Gangarosa EJ. Outbreak of typhoid fever in Trinidad in 1971 traced to a commercial ice cream product. Am J Epidemiol 1974, 100: 150-57. 16. Feldman RE, Baine WB, Nitzkin JL, Saslow MS, Pollard RA Epidemiology of Salmonella typhi infection in a migrant labor camp in Dade County, Florida. J Infect Dis 1974; 130: 334-42 17. Miner JR. The incubation period of typhoid fever. J Infect Dis 1922, 31: 296-301 18. Jordan EO, Irons EE The Rockford (Ill.) typhoid epidemic. J Infect Dis 1912; 11: 21-43 19. Mallory A, Belden EA, Brachman PS. The current status of typhoid fever in the United States and a description of an outbreak. J Infect Dis 1969; 119: 673-76. 20. Neill WA, Martin JD, Belden EA, Trotter WY. A widespread epidemic of typhoid fever traced to a common exposure. N EnglJ Med 1958; 259: 667-72. 21. Naylor GRE. Epidemiology of enteric fever. M.D. thesis, University of Cambridge, 1954. 1
Round the World From
United States ABORTION STILL A CONSTITUTIONAL ISSUE
The tenth anniversary of the historic Roe vs Wade decision has passed unnoticed. By seven to two the Supreme Court, ten years ago, ruled that abortion in the early stages of pregnancy was a decision to be made by the woman, after consultation with her doctors, and not by government, bureaucrats, or theologians. Since he wrote that decision, Mr Justice Blackman has been saddled with the responsibility-and he has been the recipient of a flood ofletters, some congratulatory but many condemning him. Anyone who comes out in favour of the decision risks becoming the target for abusive anonymous correspondence. All the same the decision is supported by the great majority, though opposition from a bitter minority continues. The right-to-life movement seems to be in internal disarray as a constitutional amendment forbidding abortion becomes ever more unlikely. Nor has the movement improved its public image by the intimidation practised by some of its supporters. President Reagan, in a speech to religious broadcasters, has said that he will insist that Congress pass legislation forbidding abortion, and there is already some evidence that his Administration is trying to get round Roe vs Wade. The Supreme Court has been hearing the arguments, both of legislatures and of organisations, who seek to limit or ban abortions, and will reveal the results of its considerations in about a year’s time. In the recent elections candidates who opposed abortion fared badly not
867 but attempts to overcome the Roe vs Wade decision go on. Restrictions imposed by municipal authorities such as Akron, Ohio, are before the courts, as are attempts to restrict abortions to hospitals. Meanwhile, the Reagan Administration, thwarted in Congress, is using administrative means to restrict this constitutional right of women. The Department of Health and Human Services has lately issued new guidelines which will determine which clinics will and which will not receive Federal funds. The use of guidelines is to avoid the opportunity for public comment that is required for formal regulations. The guidelines say that family planning clinics may not share any facilities, personnel, stationery, equipment, or supplies with any abortion clinic; the entrances and exits must be separate; and a family planning clinic must not afford any assistance to a woman seeking an abortion. One excuse is that "abortion should not be a method of family planning": the other is that the General Accounting Office, the investigative agency of the Congress, has said the DHHS should set out clear guidance on abortion restrictions.
One person to see through this ruse was Representative H. A. Waxman. He noted that the guidelines went far beyond the GAO report and represented an "organised attack on family planning" and "violated the clear intent of Congress". Significantly, Mr Waxman stated that if Federal policy was to be changed it should be "through the legislative process and not by administrative fiat". A grievance of Reagan Administration supporters has been that decisions were being made by judicial fiat of the Supreme Court rather than by the legislature.
During the recent Supreme Court hearings the Justice Department intervened in the person, no less, of the Solicitor General, Mr Rex Lee, who argued that the court should change the legal standard by which it judged the constitutionality of abortion regulations. Judge Blackman put his finger on the real issue, despite denials by Mr Lee. The Solicitor General’s brief demanded either that Roe vs Wade be overturned or that the 1803 decision of Marbury vs Madison be overturned, this being the decision which established that the Supreme Court had the right to rule on the constitutionality of actions by other branches of government.
DYING IN PEACE
reasonably wished the expensive and useless the patient be allowed to die peacefully. After all, he was 78 years old and so senile that the court agreedadmittedly after he had been dead for several weeks-that he was not capable of making his own decision and that in consequence, the family could halt the renal dialysis treatments that kept him alive. Again not unreasonably, the courts were asked by the nursing-home administration if the decision could properly be made by the family. At that point some right-to-life advocates got to know of what was going on; the nursing-home administrator instructed the nurses that right-to-life campaigners should be allowed to question the patients; and so the old man was interviewed by a physician and four nurses on behalf of the right-to-life movement. In consequence the widow claimed that her dying husband’s privacy has been violated and she brought a suit against the nursing home. The jury agreed with her and awarded her damages of$2 -8million against the nursing home; it also ruled against one of the nurses but made no award of damages. Many will feel that it was a pity the action was not brought against all those who questioned the dying man and who had no real concern with his treatment. It is about time such a blow was struck. High authority here has spoken, in connection with the abortion issue, of the "long historic concern of the American people with the sanctity of human life", but it is puzzling to know just where this concern comes from. True, we hear it from the ministers of religion, but it does not seem to have been particularly manifested in the past by any of the churches. Certainly it ill-becomes the politicians opposed The
treatments halted and that
gun control, in view of the resultant loss of human life in this country. At any rate, we can hope that this award of damages will make some of the over-zealous pause before interfering. to
NOTES FOR LANCET AUTHORS
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