London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1934

[Report of the Medical Officer of Health for London County Council]

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The first point of interest about the table is the remarkable diminution (one might almost
say disappearance) of diphtheritic rhinitis, in the second half of the year. This coincided with
the introduction in June of the practice of giving 2,000 units of diphtheria antitoxin to all the
cases receiving anti-streptococcal serum. Cases not receiving that serum did not receive
diphtheria antitoxin. The drop in diphtheritic rhinitis is, however, equally noticeable in the
non-serum (control) series of cases, and it might therefore be argued that the diphtheria antitoxin
cannot have had anything to do with the change in either series. It will be remembered,
however, that each ward contained both serum and non-serum cases, and therefore that any
measure which prevented the development of diphtheria in the serum group (as the diphtheria
antitoxin must have done if only for a period of 2 to 3 weeks after admission) would thus help
to reduce the concentration of infected cases in the ward and would thereby reduce the chances
of the non-serum cases acquiring diphtheria.
Another point in favour of the diphtheria antitoxin being the decisive factor in the change
is the fact that in both series the incidence of rhinitis itself did not materially diminish in the
second half of the year, the only difference being that after the introduction of diphtheria antitoxin,
the rhinitis was no longer associated with, or caused by, the diphtheria bacillus. This fact
will be apparent by studying columns 9 and 12 of the foregoing table in both series.

Rhinitis incidence.

Month.Serum group.Non-serum group.
Total cases adm.Simple rhinitis.Diphtheritic rhinitis.Percentage for first 7 mnths.Total cases adm.Simple rhinitis.Diphtheritic rhinitis.Percentage for first 7 mnths.
No. of cases.Per cent.No. of cases.Per cent.No. of cases.Per cent.No. of cases.Per cent.

It will next be seen from the foregoing table that there is a definite difference in the percentage
incidence of diphtheritic rhinitis in the serum and non-serum groups for the first seven
months of the year (8.9 per cent, against 13.3 per cent.). This was before diphtheria antitoxin
was being given, and it may possibly suggest that the anti-streptococcal serum itself may have had
some effect in controlling the incidence of this form of rhinitis, though obviously not to a large
extent, as the real drop did not occur until the diphtheria serum was given.
This difference in the incidence of diphtheritic rhinitis in the two groups for the first seven
months could, however,be explained equally well by suggesting that the anti-streptococcal serum by
aborting the attack of scarlet fever shortened the period during which the patient was particularly
susceptible to intercurrent disease and thus inter alia reduced the incidence of diphtheritic rhinitis.
This point, however, was not fully investigated and no attempt was made to Schick-test new
cases before or after the anti-streptococcal serum was given. There might also, of course, be a
difference if all serum cases had been put together in a ward and non-serum cases excluded.
Cases which develop diphtheritic rhinitis have to stay in hospital for very long periods—
in 1934 the average length of stay of the 66 cases of diphtheritic rhinitis was 120 days. The
average length of stay of the 55 cases complicated by simple rhinitis only was 57.8 days. Any
measure, therefore, which reduces the incidence of rhinitis cases in hospital is well worth while,
and I have adopted the practice of giving diphtheria antitoxin to nearly every case of scarlet
fever admitted.
As a consequence, diphtheria continues to be practically non-existent in the scarlet fever
wards, the occasional case which arises generally occurring in a patient who, for some reason,
has not received diphtheria antitoxin. These results are certainly unusual, as my previous
experience of scarlet fever has been that diphtheritic rhinitis has always been a most frequent
occurrence, so much so as to be almost a usual complication.