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happens that a negative result is obtained and the child returns to school only to
be re-excluded on a further positive bacteriological finding in the Council's laboratory.
The whole position is a very difficult one, and the only solution presenting itself
at present is to concentrate upon the treatment of these cases in special clinics at
certain hospitals in different parts of London.
It must be borne in mind that there are different varieties of so-called carriers
of diphtheria germs. Some of them are harbouring harmless micro-organisms
indistinguishable from true diphtheria, as seen under the microscope, but their
toxicity can only be determined by a test for their virulence. Children are allowed
to return to school when the test has proved that the germs are not virulent. Those
carrying virulent germs capable of conveying disease to a susceptible child are
excluded for treatment. Some, again, known as "passive" carriers, are themselves
immune to the disease, but through casual infection they carry the germs in their
throats or noses for quite a short period ; these quickly clear up with mild antiseptic
gargles, etc. On the other hand there are numbers of children who suffer
from various abnormalities of the throat or nose, such as enlarged tonsils and adenoids,
ear discharges, ulcers and inflamed mucous membranes due to miscellaneous causes,
who are capable of carrying and manufacturing the germs for long periods ; these
children constitute the real danger if they remain untreated. It has been found from
time to time that such cases, after tonsillectomy or other appropriate surgical treatment
has been carried out, lose their capacity for carrying diphtheria germs. In
this connection it is germane to quote from the annual report of Sir J. Robertson,
the medical officer of health of the City of Birmingham for 1926. A good deal of
work has been done in connection with the subject of diphtheria and the carrier problem
in Birmingham, and Sir J. Robertson in his report states, inter alia, as follows—
In our experience the persistent carrier is nearly always the possessor of
enlarged or unhealthy tonsils and/or adenoids. * * * *
Tonsillectomy and the removal of adenoids would appear to be a method of
great value in the clearance of the obstinate carrier of diphtheria bacilli of
proved virulence. As perhaps might be expected, clearance is more readily
obtained of organisms from the throat than the nose.
The large surface presented by the nasal mucosa for the lodgment and growth
of diphtheria bacilli makes for difficulty in clearance by any means—surgical
or otherwise.
Nevertheless, the removal of the adenoid pad must tend to cut short the
supply of organisms from the post-nasal space.
Although no clinical method is uniformly successful, it may be said that
the rational surgical treatment of the naso-pharynx is a great advance upon
the extremely unsatisfactory methods—antiseptic sprays, bacteriological
dyes, and diphtheria vaccines—hitherto available for the attempted clearance
of the convalescent diphtheria carrier.
There is no doubt that the chronic carrier of organisms of proved virulence
is at present an important factor in the spread of infection and must be considered
in quite a different category to the casual or transient carrier of harmless
diphtheroids. It is important wherever possible to secure the bacteriological
clearance of these chronic carriers. But important as he is in the spread of
infection at the present time, he might be rendered relatively or even absolutely
unimportant by the active immunisation against diphtheria of children of
susceptible ages.
The chronic carrier of virulent diphtheria bacilli who is always himself
immune to the disease, can do no damage amongst a population which has
also been rendered actively immune. The tragedies of the late case of diphtheria
coming under treatment only when anti-toxin even in the largest doses can be
of no avail will then cease to occur.