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The report of the Medical Superintendent of Guy's Hospital has proved of
considerable value in throwing more light on the problem of the diphtheria carrier.
The following notes are largely based upon this report.
Carriers are divisible into those in whom:—
(a) The infection is entirely in the nose.
(b) The infection is in both nose and throat.
(c) The infection is in the ear as well as the nose.
(d) The infection is in the throat only—usually the tonsils.
The nasal cases (simple and complicated) formed the majority and were generally
difficult to treat. In such cases an operation for removal of unhealthy tonsils or
adenoids was insufficient to remove the infection. Many of these cases were found
to occur in children susceptible to diphtheria, and although harbouring the germs,
they neither developed the disease nor became immune. It appears that in these
cases the bacilli lived a purely saprophytic existence in the nasal discharges, having
no direct contact with the mucous membrane of the nose. Apart from clearing up
any nasal abnormality or the use of mild nasal douches these children were treated
with autogenous vaccines or with a polyvalent vaccine prepared from 12 virulent
strains of the Bacillus Diphtheria.
With regard to ear cases, it may be stated that most ear discharges contain
diphtheroid organisms of some kind, and these are usually avirulent. When virulent
diphtheria germs are found in such cases they are traceable, as a rule, to infection
by a true "carrier." Some years ago a severe outbreak of diphtheria at one of the
Council's schools was traceable to a number of children with ear discharge who
attended the building for attention by the school nurse. The attendance of these
children was thereupon discontinued and the outbreak came to an end. Cases of
this kind are treated like nasal "carriers," viz., by means of douches and autogenous
vaccines.
The treatment of children harbouring diphtheria germs in the throat is more
clearly defined inasmuch as the site of infection is to be found in the tonsillar crypts.
If a section of the tonsils is made the micro-organisms will be found deep down at
the base of the crypts, even after a series of negative swabbings has been taken,
thus showing the futility of relying upon negative bacteriological results as a proof
of freedom from infection in such cases.
The following broad conclusions may, therefore, be drawn as a result of the
experience obtained up to the present at the diphtheria carrier clinics:—
(1) In cases where the diphtheria bacilli are confined to the tonsils, the
condition invariably clears up after tonsillectomy has been performed.
(2) Diphtheria micro-organisms found in the nose live a purely saprophytic
existence and are due to nasal abnormalities of various kinds, which provide
a suitable habitat for the existence and multiplication of the germs. When the
causative defect is cured the bacilli disappear not only from the nose but from
other parts which have been infected from this source. The cure of nasal
abnormalities may even exhaust the skill of the expert rhinologist and may be
a very difficult and trying procedure, especially in young children. The treatment
varies from the removal of foreign bodies, e.g., peas, and on one occasion
a sponge, to the clearing up of infection in the nasal sinuses. Each case demands
careful examination and individual attention.
(3) A polyvalent vaccine was used as a routine composed of 12 virulent
strains of diphtheria germs isolated from carriers. Usually four injections are
given at weekly intervals of doses containing 5, 10, 15 and 20 million dead germs
respectively.
It is hoped that these conclusions may be of value in furthering the study and
practical treatment of a condition which has been the source of much anxiety and
perplexity to public health and school medical authorities and which is undoubtedly
Bacillus
Diphtherise.