(From The Anti-Vivisection Journal).
THE letter quoted in full written by Dr. James in the British Medical journal of August 4th in our last issue,., on diphtheria diagnosis provoked a flood of correspondence from al over the country. The correspondence on the subject.
It may be well to recall that Dr. James drew attention to the fact that by the use of the use of the swab negative cultures were frequently obtained in severe and fatal cases and positive ones in slight cases in which the throat is clear and only slightly inflamed. The influence that this state of affairs, if universally existing, must have upon any statistical estimates of case mortality, must be devastating. It is difficult to conceive how any acceptable statistical estimates of case mortality, must be devastating.
Its is difficult to conceive how any acceptable statistics can be produced on such a basis and anyone aware of the position would be justified in accepting these statistics only with the greatest reserve. It would be pertinent to enquire upon what diagnostic basis the figures supplied by the basis of diagnosis may well be the explanation of the great discrepancies between the figures which divers of the hospitals produced (we are thinking of the tables published in the old Metropolitan Asylums Boards annual reviews). Finally, we must also demand by what statistical method the proof of the efficacy of diphtheria antitoxin was obtained.
To come to our correspondence on the subject of the swab and the diverse views revealed thereby, in the British Medical Journal of August 11th, Dr. Sanctuary writes:.
“as Medical Officer to the isolation hospital of this area (Bridport), I have had some seventy cases of diphtheria admitted in the last six months, quite a number of which, though absolutely definite clinically, returned a negative swab. The swab in diphtheria must, I consider, be regarded in the same light as the examination of sputum in tuberculosis-that is, a negative swab is no contraindication of the presence of the disease, while a positive one confirms the presence of the micro- organisms.”
He advocates the immediate administration of serum in all doubtful cases without reference to the swab and is one of the big antitoxin dose school:
“… I have personally administered up to 150,000 units in doses of 40 ,000 units, with no more effect than an irritating serum rash, allayed by hypodermic injection of pituitrin and / or Calamine lotion”.
It is surprising that someone does not suggest the routine use of pituitrin or adrenalin with these injections.
In the British Medical journal of August 18th, Dr. Crawford writes:
“The practice of swabbing throats of patients seriously ill with diphtheria, instead of their immediate admission to hospital being secured on clinical grounds, has long continued to be the despair of physicians engaged in preventive medicine”.
He approved of the suggestion that doubtful cases should be be referred to area diphtheria specialists. Dr. French writes:.
“Does Dr. James seriously advise that the policy of swabbing sore throats should be abandoned. It is surely common knowledge that diphtheria may be, often is, spread by carriers, whose throats defy diagnosis clinically even by those familiar with the diphtheritic throat. In my experience the disease does not always follow the text book law of signs and symptoms… any policy not involving the free use of the swab is scientific heresay indeed”.
Dr. Wallis joins the diphtheria antitoxin first, diagnosis after, in doubtful cases, club.
In the issue of August 25th the correspondence reaches its climax, no fewer that in his district they pay the doctor five shillings for every swab he sends for examination, and that as the results of ten years constant swabbing, he find that:.
“Many swabbed throats in which no clinical resemblance to diphtheria was present, are found to be diphtheritic, and others which appeared quite characteristic are found to be negative.. It is among the cases in which no one-not even Drs. James and Sanctuary-would suspect diphtheria that the ambulatory and therefore dangerous case is found”.
He further opines that expert examination is not of any value in really early cases and says:.
“It is also impracticable to put every sore throat into hospital or to give every patient suffering from sore throat 20,000 units of antitoxin”.
Dr. James, the originator of the combat, refers to carriers saying:.
“Dr. French should remember that, for every supposed carrier whom he succeeds in isolating, there are many more at large who are probably doing useful work in helping to immunize the susceptible population. further, a report that organisms morphologically resembling the Klebs-Loeffler bacilli are present in a culture is not a sure indication that the person concerned is a carrier or disseminator of virulent organisms”.
Dr. Newell, D.P.H., suggests that one of the uses of the swab is “to give assurance to parents”, averring that in these days many will no be satisfied with anything less; another use, to give “information in the immunization of a patient against diphtheria” whatever this may mean. He further states that:.
“The existence of non-virulent diphtheria does not mean the existence of the disease, though it may or may not mean a potential carrier. A negative report is no proof of the nonexistence of the disease. I have had negative reports on cases sent to hospital and positive reports from other laboratories. why some swabs are negative and others from the same case positive, I cannot explain. The clinical picture of diphtheria is clear and the most reliable evidence of the diseases”.
Mr. Constant Ponder, bacteriologist to Kent Country council attacks the method of examining swabs by making cultures which take some time, whilst the method of direct smear can be used as an immediate test, to be confirmed by culture later if desired, he says:.
“The only pitfall which must be avoided results from the fact (for which I am unable to give any explanation) that in adults diphtheroid organisms are sometimes seen which closely resemble the diphtheria bacillus are sometimes seen which closely resemble the diptheria bacillus as seen in swabs from a childs throat. Consequently, we do not report on direct smears taken from a patient over the age of eighteen”.
On October 6th, Dr. Folliott writes to the British Medical Journal.
“No one knows better than the general practitioner that scientific tests are rarely a substitute for clinical observation and that a negative swab does not preclude the disease when clinical signs are suspicious… In all cases, when diphtheria has been diagnosed and confirmed, I immediately swab all the other members of the household, children and adults, and inject 2,000 units of antitoxin intramuscularly”.
Later, referring to the public keeping sore throats to themselves:.
“If the public fails to learn, the children will have to be immunized”.
Dr. Folliott is evidently one of these no-nonsense people.
Finally (as far as this article is concerned) Dr. Belam gives instructions how to take a swab properly, the practitioner”.
“Planting the swab exactly upon the suspected area on the tonsil or elsewhere, but should remember that in quite a number of cases a nasal swab will give a positive result where a throat swab will not”.
Dr. Belam believes that most cases of faucial diphtheria not treated with antitoxin will prove fatal, and regards it as a miracle if such a case can be saved if antitoxin be not given before the fourth day. The same he believes about faucial diphtheria giving negative swabs, for he says that unless treated as diphtheria they will certainly die.
What the ordinary person is to make of the “diptheria of bacillus,” virulent or mildly virulent or non-virulent, the person having typical diphtheria or having a typical diphtheria, or being a sore throat but a diphtheria carrier or being not a carrier but having typical diphtheria or having a typical diphtheria, or being a sore throat but a diphtheria carrier or being not a carrier but having virulent bacilli without having diphtheria, or being over eighteen and having diphtheroids, we do not now.
We also would like to know Dr. Belams technique for planting a diphtheria swab exactly upon the suspected are of a hostile head twisting squalling child of anywhere between eighteen months and five years.
What principally emerges is how far more reliable clinical medicine is than that of the laboratory and that there is room for a little clarification of the orthodox views of diphtheria diagnosis, which will certainly not be views of diphtheria diagnosis, which will certainly not be simplified by the immunization of the whole community.