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difficulty. Carriers are often perfectly healthy to all appearances, and as they cannot
be certified as "suffering from" diphtheria, isolation is sometimes difficult to effect,
and requires considerable persuasion in order to have it carried out.
Diphtheria is highly infectious, and is particularly fatal among children under the
age of five years. It is spread among scholars, and in families, through the agency of
carriers. No uniform method has yet boon discovered by which carriers can bo rendered
harmless, although in certain cases presenting abnormal conditions of the throat and
nose, e.g., enlarged septic tonsils, surgical treatment has achieved the desired effect.
Individuals may be divided into two classes—those who aro 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 small-pox,
natural antitoxin can be made to develop in susceptible individuals. This natural
antitoxin 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
immunization, 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 immunized. The
test is also used to tell whether the three immunizing injections have proved effective,
and a susceptible individual having received three immunizing 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 three immunizing
injections are insufficient to create immunity in the particular case, and it will be necessary
to repeat the series of injections. In a few rare instances three and even four series of
injections have been necessary before the person developed immunity to diphtheria as
ndicated by the Schick test. This re-testing after a course of immunizing injections
may be compared to the inspection of vaccinations; unless a vaccination is inspected
about the eighth or ninth day, there is no proof that the vaccination has been
successful.
This method of testing and immunization was put into practice in New York by
Park in 1913, and since then some 50,000 school children have been treated in that city.
It is noteworthy that 90 per cent, of those have remained immune to diphtheria after
seven years. In this country the Ministry of Health have carried out extensive tests,
and have introduced this form of immunization into 14 residential schools. The Medical
Officers of the Ministry have tested 4,528 children, and have immunized 1,400. Among
the former there were 265 cases of diphtheria before immunization, but during the year
following this treatment there were only 2 cases.
In Edinburgh some 4,000 school children have been treated by the Sanitary Authority,
and the method has been widely practised in the Fever Hospitals of Manchester and
Birmingham. In the Metropolitan Borough of Holborn, since 1922, immunization work
has been carried out for children under school age attending the Maternity and Child
Welfare Contre; the number tested was 642, of which 460 were positive, and 172 were
negative or immune, 10 did not attend for the test to be inspected.
In the latter part of 1924 and beginning of 1925 there was an outbreak of diphtheria
at the Newport Market Army Training School. It became evident that the infections
which kept breaking out were caused by carriers among the scholars. The Medical
Officer of Health arranged for the scholars to be immunized in the manner which has
been describod above, and obtained the authority of the Public Health Committee for
the necessary expenditure on the testing material, which amounted to £1 12a. 2d. Tho
(6026)q _ o