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the original case was proved to be responsible for two secondary or "return cases." In the
remaining three return cases there was no direct evidence that the infection had been contracted
from persons returning from hospital.
During the year 1,588 throat swabs were examined at the Lister Institute at the expense of
the Council, and of these 246 gave a positive diphtheria result.
It is well established that outbreaks of diphtheria may originate from persons who have the
germs of the disease in the throat or nose, but show no signs of illness. Such persons are called
"carriers" and with a view to discovering the possible existence of any of these in connection with
limited outbreaks where the source of infection was unknown, a number of throat and nose swabs
were taken by medical men at my request or by myself. These swabs are included in the 1,588
referred to above. In a number of cases germs of diphtheria were discovered; but germs so found
in apparently healthy throats or noses may be of a virulent type (capable of conveying dipthheria
infection to other persons) or of an avirulent type (incapable of conveying diphtheria infection to
other persons), therefore it is necessary to ascertain the particular type of organism present before
submitting the patient to prolonged isolation and treatment.
Several persons at a public institution contracted diphtheria and as the circumstances pointed
to the fact that the infection came from someone in that building, a number of inmates were swabbed.
In one of these diphtheria germs of a virulent type were found and, following isolation, no further
cases developed. At another institution several cases of diphtheria occurred and, after swabbing
the throats of other inmates, it was discovered that one had virulent germs of diphtheria in his throat.
He was removed to hospital, and no further cases developed. At a boys' home four cases of diphtheria
occurred within the space of three days. Following the removal of these cases to hospital,
all the boys in the home were carefully examined and swabs were taken in about twelve doubtful
cases. Three of these proved to be positive for diphtheria. The patients were removed to hospital,
and no further cases occurred.
These cases demonstrate that careful investigations for the source of infection do from time
to time well repay the labour undertaken, for they enable persons in an infective condition who are
quite innocent of the fact to be isolated. Doubtless many a localised outbreak can be terminated
in this way.
Under the Anti-toxin Order, 1910, the Council are empowered to supply diphtheria antitoxin
for administration to patients who are too poor to pay, and on signing the necessary
declaration that the patient cannot afford specific treatment, a medical man can obtain a free
supply from Mr. Worsley, Chemist, at No. 135, Ladbroke Grove, W.11, or from the Public Health
Department at the Town Hall. The anti-toxin is obtainable at all hours of the day and night
from Mr. Worsley's premises, and during office hours from the Town Hall. When the Town Hall
is closed, applications for anti-toxin can be made to Mr. Sutton, an Officer of the Department,
who lives at No. 1, Hornton Place, Hornton Street (only a few yards from the Town Hall).
The Council loan syringes with portable sterilizers to doctors for the purpose of administering
the anti-toxin. Medical men administering the Council's anti-toxin to poor persons are, on application
to the Medical Officer of Health, paid a fee of 5s. per patient treated.
In 1926, the Borough Council supplied 268,500 units of anti-toxin for 80 patients at a cost of
£18 18s. Od.
Home disinfection and school exclusion are carried out as in cases of scarlet fever.
The Schick Test and Immunisation.
Individuals may be divided into two classes—those who are naturally immune to diphtheria
infection and those who are susceptible. It invariably happens in an outbreak of diphtheria that a
number of cases occur, some perhaps of a fatal nature, before the infecting agent or carrier can be
discovered. We have, however, at our disposal the means by which all susceptible individuals
can be protected against infectious carriers. By means of inoculation, somewhat similar in nature
to vaccination against smallpox, natural anti-toxin can be made to develop in susceptible individuals.
This natural anti-toxin creates immunity to diphtheria, which lasts for many years and perhaps
during lifetime.
In order to tell whether an individual is susceptible, and requires this method of immunisation,
a test is employed. This is called the Schick test, and it is performed on the skin of the forearm, a
trace of diphtheria toxin being injected under the skin. If the individual is susceptible, a small
circular red wheal arises round the site of injection in the course of a few days. The absence of any
such reaction in the skin denotes that the person is naturally immune and, therefore, does not
require to be immunised. The test is also used to tell whether the immunising injections have proved
-effective, and a susceptible individual having received three immunising doses should give a negative
result to the Schick test, say at the end of three months. This would prove that he is immune or
protected. If the test proves positive it is evident that the three immunising injections are insufficient
to create immunity in the particular case, and it will be necessary to repeat the series of