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82
With the object of securing greater control over carrier cases, the medical officers of health in
seven of the metropolitan boroughs (Lambeth, Wandsworth, Paddington, Battersea, Hackney, Greenwich
and Kensington) require them to be officially notified, and in this connection 99 notifications of
cases of bacteriological diphtheria discovered among school children were forwarded during the year.
This method is open to objection, however, inasmuch as, if widely adopted, it creates artificial epidemics:
there is also the further point that, in view of the length of time some of these unfortunate carriers are
harbouring germs, it would be impracticable, even if desirable, to insist on strict isolation, nor would
it be desirable to treat them in an isolation hospital intended for the accommodation and care of acute
cases. In fact, the medical superintendents of Metropolitan Asylums Board institutions, as a rule
object to receiving carrier cases into their hospitals, and most of the general hospitals are also reluctant
to receive them in their out-patient departments. In one hospital, however, limited numbers of carriers
are being dealt with each week as out-patients, and a special form of vaccine treatment is being under
taken. Special methods of treatment are also being carried out under the supervision of Dr. Wells,
one of the Council's divisional medical officers, and his report is appended.
Report on
" Diphtheria
Carriers;'' by
Dr. A. G.
Wells.
"During the year 1920, thirteen cases of "diphtheria carriers" were submitted to me to be
investigated and supervised. The plan adopted was to make a careful clinical examination of the nose,
throat and ears, as well as a bacteriological test. In cases which showed unhealthy tonsils and nasopharyngeal
growths an attempt was made, as a first step, to get this condition dealt with by operation.
This was not an easy matter. If the attempt was made at a hospital, the case was refused when it was
known to he a "diphtheria carrier," though in point of fact many undiscovered cases of this kind must
be operated on daily. Some were, however, operated on more or less satisfactorily, and others, again,
did not require such an operation. If ear discharge was present, that, of course, was treated concomitantly.
"The next step was the treatment of the nose and throat with a solution containing potassium
chlorate and other salts, which has a solvent action on diphtheritic material. The practice was to
douche the nose and throat, but the treatment could only be carried out at home in most of the cases.
Weekly swabs were taken, and if a negative result was not recorded after a short time, the treatment
was varied.
"Altogether nine cases (having cleared up during the treatment) were returned to school after three
negative results. Six cases responded with a negative result within a week, but one of these relapsed.
One responded after two weeks, and one after three weeks. The other cases have been intermittently
positive and negative, and, with one exception, have not yet cleared up. One of the unsuccessful cases,
however, was found not to have had any treatment at all for the nose (which was constantly positive),
while the throat, which had treatment, varied in result.
"Of the above thirteen cases, eleven had various degrees of nasal catarrh and rhinitis, six had
definite pharyngeal catarrh, three had enlarged tonsils, five had palpable adenoids, and three of the
cases were operated on. Other conditions found, which probably have a definite relation to the persistence
of the organisms, are ulcers in the nasal mucosa, hypertrophy of the turbinals, deflected septum,
in fact most pathological conditions of the nose.
"There did not appear to be any very marked differences in the cases, with the exception that in
two of those that cleared up the defects were very slight, and consequently there were no indications
to go upon before treatment was administered, as to which cases would be likely to clear up and which
would not. In view of the fact that about 8 per cent. of all throats show organisms resembling B.
Diphtheriæ, which are non-pathogenic when inoculated into guinea pigs, it would seem hardly justifiable
that cases should be kept away from school for an indefinite period. In the absence of any clinical
symptoms in the patient or of actual clinical cases of diphtheria at the school, it may be advisable in
the future to allow such children to attend school."
Local
persistence of
Diphtheria.
Instances of the persistent prevalence of diphtheria in certain schools or localities over a period
of two or three years have frequently been observed (see annual report for 1912, p. 154), and in this
connection it will be of interest briefly to record a series of outbreaks which occurred in North-East
London during the period 1918-20. The area affected may be described as a rectangle measuring,
roughly speaking, 3 miles long and 2 miles wide, and comprising the southern part of the borough of
Hackney, which included the Dalston and Homerton groups shown in the following table ; the whole
south-eastern border of the borough of Islington with a small part of Stoke Newington, represented by
the Stoke Newington and Islington groups ; and the northern half of the borough of Shoreditcli,
comprising the Hoxton and Haggerston groups.