View report page

132
an equally important, if not greater, part in the spread of infection. The clinic has,
therefore, accepted for treatment cases of pre-school age referred by the Medical
Officer of Health of the Borough.
It must be understood that the initiation and carrying on of the clinic
necessitated a good deal of preliminary work on the part of the surgeon and bacteriologist,
and special equipment had to be provided. Further, each individual case
requires specialised attention. For instance, the surgeon must survey the whole
field of the mucous membranes of the throat, nose and ear in order to discover the
existence of any abnormal conditions, and, if found, to decide whether the pathological
state in question is responsible for providing a habitat for the diphtheria
germs—there may be more than one seat of the mischief—and he must also make
up his mind whether the infection is superficial and, therefore, vegetative, or if the
bacilli are entrenched in a more deep seated part necessitating removal by operation.
The bacteriologist, on the other hand, is required to make a similar exhaustive
survey and by regional swabbings to discover the site of the " germ factory." On
isolating the germ he must test it for virulence or pathogenicity and ascertain whether
the child is an immune person.
These requirements are set out in some detail in order to show that the time and
labour involved in dealing with such cases cannot be estimated on the same plane
as ordinary straightforward minor ailment cases.
The clinic proved to be a success, and a year later (27th October, 1927) an
extension of these clinics was granted at three other hospitals, viz., London, St.
Mary's and St. Thomas's Hospitals, if arrangements could be completed, at a cost
not exceeding £200 for the financial year (1928-29). As a result two additional
clinics have been provided, one at St. Mary's Hospital (Inoculation Department),
and the other at the London Hospital (O.P. Department). Unfortunately the
negotiations with St. Thomas's Hospital could not be brought to fruition, owing
to practical difficulties at the hospital.
The existence of these clinics has served the dual purpose of making special
provision for the treatment of the obstinate diphtheria carrier, who has for long been
a source of difficulty both to the medical practitioner and to the public health
service, and of providing facilities for the intensive study of the conditions which
give rise to the " carrier " state.
The deductions arrived at, more especially at Guy's Hospital, where the scheme
has been in operation for a longer period, confirm to a large extent the observations
of the school medical service over a large number of years. The more important
results which have been learned are as here set out:—
Young children constitute the large proportion of " carrier " cases, and many
of them are under 5 years of age. The propensity to harbour the germs is found
especially among those children who have recovered from a clinical attack. The
inability to throw off the infection is due to a pathological condition of the mucous
membrane. In young children the site is usually in the nose, due to such conditions as
deflected septum, adenoids, etc., whilst in others it is usually to be found in enlarged
tonsils deep down in the crypts where no antiseptic can penetrate.
Altogether 217 children have been treated at these clinics, of which 175 were
at Guy's Hospital, 26 at the London Hospital and 16 at St. Mary's Hospital. In
22 cases the tonsils and adenoids were removed, mostly at the London Hospital,
where 16 of such operations were performed among the 26 children referred for
treatment. The following table giving an analysis of 140 cases referred to Guy's
Hospital will be of interest:—
Cases
referred
to clinic.
Discharged
as not true
carriers.
Doubtful.
True
carriers.
Nose
cases. 1
Nose
and ear.
Nose
and throat.
Throat
only.
Operation.
140
70
24
46
16
1
18
11
4