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Chapter VI

Communicable Diseases, Table of Contents

CHAPTER VI

DIPHTHERIA

STATISTICAL CONSIDERATIONS

The influence of diphtheria on the admission rate of the Army was not sufficient to place it among the 30 most important diseases, but it stood eighteenth among causes of death and twenty-eighth for time lost.

The interesting features of its occurrence are: It was decidedly more prevalent among white enlisted men than among colored; the case fatality rate was higher among the colored; there were only three instances of the prevalence assuming epidemic characteristics.

As shown in Table 33, the total annual strength of the Army for the period 1917-1919 was 4,128,479; the annual admission rate per 1,000 for the period was 2.64; the death rate, 0.04 per 1,000; and the noneffective rate, 0.21 per 1,000. Among native troops (Philippine Islands, Hawaii, and Porto Rico) the disease incidence was insignificant, 2 cases occurring in a strength of 36,000 and no deaths. The annual admission rate among officers for the entire period was 1.56 per 1,000, as compared to 2.72 for enlisted men; the annual death rates, respectively, were: Officers 0.03 per 1,000 and enlisted men 0.04; the noneffective rates 0.10 per 1,000 and 0.22 per 1,000.

TABLE 33.-Diphtheria. Admissions, deaths, discharges for disability, and days lost, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000 strength

 

Total mean annual strengths

Admissions

Deaths

Discharges for disability

Days lost

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Non-
effective ratios per 1,000
strength

Total officers and enlisted men, including native troops

4,128,479

10,909

2.64

177

0.04

80

0.02

317,050

0.21

Total officers and enlisted men, American troops

4,092,457

10,907

2.67

177

.04

80

.02

317,023

.21

Total officers

206,382

322

1.56

7

.03

1

.00

7,835

.10

Total American troops:

 

 

 

 

 

 

 

 

 

    

White

3,599,527

9,650

2.68

154

.04

77

.02

285,080

.22

    

Colored

286,548

205

.72

5

.02

2

.01

4,863

.05

    

Color not stated

---

730

---

11

---

---

---

19,245

---

         

Total

3,866,075

10,585

2.72

170

.04

79

.02

309,188

.22

Total native troops (enlisted)

36,022

2

.06

---

---

---

---

27

.00

Total Army in the United States, including Alaska:

 

 

 

 

 

 

 

 

 

    

Officers

124,266

180

1.45

4

.03

---

---

4,182

.09

    

White enlisted

1,965,297

5,577

2.84

89

.05

51

.03

137,369

.19

    

Colored enlisted

145,826

127

.87

3

.02

2

.01

2,901

.05

         

Total enlisted

2,111,123

5,704

2.70

92

.04

53

.03

140,270

.18

         

Total officers and men

2,235,389

5,884

2.63

96

.04

53

.02

144,452

.18

U.S. Army in Europe, excluding Russia:

 

 

 

 

 

 

 

 

 

    

Officers

73,728

137

1.86

3

.04

1

.01

3,563

.13

    

White enlisted

1,469,656

3,921

2.67

61

.04

22

.01

143,552

.27

    

Colored enlisted

122,412

74

.60

1

.01

---

---

1,923

.04

    

Color not stated

---

728

---

11

---

---

---

19,062

---

         

Total enlisted

1,592,068

4,723

2.97

73

.05

22

.01

164,537

.28

         

Total officers and men

1,665,796

4,860

2.92

76

.05

23

.01

168,100

.28

Officers, other countries

8,388

5

.60

---

---

---

---

90

.03

U.S. Army in Philippine Islands:

 

 

 

 

 

 

 

 

 

    

White enlisted

16,995

3

.18

---

---

---

---

82

.01

    

Total enlisted

21,451

3

.14

---

---

---

---

82

.01

U.S. Army in Hawaii, white enlisted

16,161

---

---

---

---

---

---

47

.01

U.S. Army in Panama, white enlisted

19,688

19

.97

---

---

---

---

206

.03

U.S. Army in other countries not stated:

 

 

 

 

 

 

 

 

 

    

White enlisted

---

26

---

1

---

---

---

919

---

    

Colored enlisted

---

1

---

1

---

---

---

6

---

    

Color not stated

---

2

---

---

---

---

---

183

---

         

Total*

14,232

29

2.04

2

.14

---

---

1,108

.21

Transports:

 

 

 

 

 

 

 

 

 

    

White enlisted

97,498

104

1.07

3

.03

4

.04

2,905

.08

    

Colored enlisted

10,535

3

.28

---

---

---

---

33

.01

         

Total

108,033

107

.99

3

.03

4

.04

2,938

.07

Native troops enlisted:

 

 

 

 

 

 

 

 

 

    

Philippine Scouts

18,576

1

.05

---

---

---

---

15

.00

    

Hawaiians

5,615

1

.18

---

---

---

---

12

.01

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.
*Separate strength of white and colored not available.


235

Table 34 shows the number of admissions and deaths, together with the annual rates, by months, of white and colored enlisted men, United States Army, for both the United States and Europe.

TABLE 34.-Diphtheria. Admissions and deaths, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000 strength


236

TABLE 34.-Diphtheria. Admissions and deaths, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000 strength-Continued

The following summary from Table 34 shows the annual admission rates by location, years, and race:

For white troops in United States:


For colored troops in United States:

    

1917

3.42

    

1917

1.56

    

1918

2.62

    

1918

.76

    

1919

2.78

    

1919

1.04


For white troops in American Expeditionary Forces:

For colored troops in American Expeditionary Forces:

    

1917

1.60

    

1917

4.15

    

1918

2.90

    

1918

.70

    

1919

2.30

    

1919

.46

 


237

A study of these figures shows that white troops had a much higher rate in the United States during 1917 and 1919 than did those in the American Expeditionary Forces; while the latter, during 1918, the period of greatest activity overseas, had the higher rate. Seasonal variation was not significant, except that in 1917 the prevalence at home remained consistently high throughout the year; while in 1918 and 1919 it was high during late winter and spring, and low during the summer. In the American Expeditionary Forces the incidence rate was excessively high in July, 1917; it then dropped to a low point and remained low until late winter, when it climbed rapidly, reaching the peak in March and remaining fairly high until midsummer. During 1919 in the American Expeditionary Forces the rise came in June and, except during September, remained high to the end of the year, reaching the high point of the war (14.36 per 1,000) in December.

There seems very little correlation throughout the period between the rate of prevalence at home and abroad. One might expect to find a lag in the American Expeditionary Forces curve, showing a summer rise, produced by an influx of carriers from the spring peak in the United States; there is some indication of such a condition in the early part of 1918.

Considering the whole period, white troops in the United States had an annual admission rate of 2.84 per 1,000, while those in Europe had 2.67. Among the colored troops the rate at home was 0.87 and in Europe 0.60. There is nothing significant in the difference shown between troops at home and abroad, and comparison is hardly justified. All troops numbered as in the American Expeditionary Forces were also counted at some period among home troops, and it is reasonable to presume that unknown passive carriers were sources both at home and in Europe.

Table 33 indicates that for the whole period, April 1, 1917, to December 31, 1919, the admission rate for the Army in the American Expeditionary Forces was 2.92 per 1,000; while that of the Army at home was 2.63. This difference of 29 cases per 100,000 men is not significant, and was undoubtedly influenced, particularly in the early part of the period, by imported cases. For example, in December, 1917, the strength of colored troops was 5,346 (Table 34), or 3 per cent of the entire strength, yet they furnished 3 cases, or 15 per cent of the total (21) for that month. It is quite probable that the cases in question originated in the United States.

OCCURRENCE IN THE UNITED STATES

Figures for the Army in the United States (Table 33) show a total of 5,884b cases in an aggregate strength of 2,235,389, or an annual incidence rate of 2.63 per 1,000. The deaths totaled 96, making an annual rate of 0.04 per 1,000 and a case fatality rate of 1.6 per cent, or 16 deaths per 1,000 cases.

As noted previously and shown graphically in Chart XXX, there was a noticeable difference between white and colored troops in resistance to diphtheria. As conditions of exposure were practically the same for both, the variation in prevalence is best accounted for by the hypothesis of crediting the colored soldiers with higher resistance or less susceptibility. However, when the appar-

bThis figure represents primary admissions.


238

ent higher immunity in the latter race is broken down by invasion, there is less resistance to the toxic effect of the microorganism, and the case fatality is much higher than among the whites; 23 per 1,000 as against 16 per 1,000.

The days lost for each case (Chart XXX) are practically the same for white and colored, and the noneffective rate correlating with the admission rate, is, of course, much higher for the white troops.

Officers in the United States (Table 33) show an aggregate strength of 124,266 and 180 cases, or an annual rate of 1.45 per 1,000; among these there were 4 deaths, giving a case fatality of 2.22 per cent, or 22 deaths per 1,000 cases, which is considerably higher than that for the enlisted men (16 per 1,000). It is interesting to note (Table 33) that the officer strength, 124,266 is approximately within 20,000 of the colored strength, and the case fatality rates are fairly close, the difference being 1 death per 1,000 cases.

The lower incidence rate among officers is probably due to their more advanced age, as we know that immunity to diphtheria increases with each year beyond childhood. The higher fatality rate among cases may be assigned to the same hypothesis applied to colored troops. It is well known in all children's diseases attacking adults that the case fatality is high. Presumably, the adult victims are a small percentage who have built up little or no immunity, and the virus finds a favorable soil for development.

BY CAMPS

A study of Chart XXXI and Table 35 shows at once that camps in the central area had a decided influence on the general admission rate. Camp Doniphan, Okla.; Camp Pike, Ark.; Camp Funston, Kans.; Camp Grant, Ill.; and Camp Dodge, Iowa, furnished 17 per cent of the aggregate strength and 50 per cent of the diphtheria.

These camps were populated from the agricultural area of the United States, and possibly a large proportion of the men had never been subjected to the exposure incident to density of population and industrial conditions of the East, and hence had acquired less immunity. Chart XXXII shows graphically the decided susceptibility of men from the agricultural States. It is quite true that many of our southern camps drew men from agricultural regions also, but a large percentage of their strength was colored, which, as already shown, had a decidedly racial resistance. The northwest area had a rate just below the average for the United States, but this position was characteristic of the men from this section, for all causes of admission.


239

CHART XXX


240

TABLE 35.-Diphtheria. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919, inclusive. Absolute numbers and annual ratios per 1,000 strength

Among the camps in the Central United States which had high admission rates, the following case fatalities are found (calculated from cases and deaths, Table 35):

Camp Pike, Ark.:

Camp Funston, Kans.:

    

Cases

226

    

Cases

345

    

Deaths

8

    

Deaths

5

    

Case fatality (per cent)

3.54

    

Case fatality (per cent)

1.45

Camp Grant, Ill.:

Camp Doniphan, Okla.:

    

Cases

216

    

Cases

577

    

Deaths

4

    

Deaths

7

    

Case fatality (per cent)

1.85

    

Case fatality (per cent)

1.21

Camp Dodge, Iowa:

 

    

Cases

173

    

Deaths

3

    

Case fatality (per cent)

1.73

 


241

CHART XXXI


242

Chart XXXI indicates very clearly that Camp Doniphan, Okla., led all stations in the United States as a diphtheria center. Keefer, Friedberg, and Aronson1 show that sporadic cases were present through the period October, 1917, to February, 1918, when the admissions increased rapidly; there was a slight fall during the first week of March and then a secondary rise, reaching the highest point during the week ending April 7.

The outbreak studied by these authors covered the period October 7, 1917, to May 31, 1918, and included 461 of the 577 cases occurring between April 15, 1917, and December 31, 1919. The undue prevalence was rather sharply limited to February and March. A careful study was made of carriers and, as might be expected, the carrier rate paralleled the morbidity. As indicated above, the case fatality was low, pointing to low infectivity of the microorganism. A study of occurrence by organizations showed decided resistance on the part of those coming from urban centers, except among hospital personnel, where continued exposure to presumably heavy infection broke down the resistance of urban as well as rural dweller.

CHART XXXII

In all other camps diphtheria was present, but did not show any alarming increase other than an occasional slight rise in admission rates, with seasonal changes, and the addition of carriers coming with augmented population.

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

Table 33 shows a total mean annual strength of 1,665,796 in the American Expeditionary Forces, with 4,860 admissions, or an annual rate of 2.92. There were 76 deaths, giving a case fatality of 1.56 per cent, or 15 deaths per 1,000 cases. While the annual admission rate (2.92 per 1,000) is higher than that for troops in the United States (2.63), the period of higher incidence is practically limited to the spring of 1918 and the fall of 1919. The latter period was one of markedly reduced strength, with concentration of troops in the occupied area in Germany, and increased contact with civilian carriers in younger age groups. The rate of incidence was not significant; for example, in December, 1919, there were only 22 cases. Since the strength now had fallen to 18,379, the resultant annual rate for the month (14.36 per 1,000) is high.


243

Considering diphtheria as a divisional problem, which it properly became in the American Expeditionary Forces, there were only 2 divisions of the total 42 in which the disease became at all alarming. The history of diphtheria in each unit was traced by Neal and Sutton.2 Both these divisions came from camps in the United States where there was undue prevalence, namely, Camp MacArthur, Tex., and Camp Doniphan, Okla. It is quite reasonable to presume, then, that each division brought its own sources of infection in carriers, and the necessary crowding in trains, transports, and billeting provided increased means of spread.

The two divisions affected were the 32d, which came from Camp MacArthur, Tex., and the 35th, from Camp Doniphan, Okla.

The 32d Division had a constant source of known infection from the time it left camp until it reached its area in France; that is, cases developed in Camp MacArthur just before departure of the division (February 4, 1918); others appeared en route to Camp Merritt, and while in this camp awaiting embarkation. Various units of the division were separated for transportation to Europe. It was well along in April, 1918, before the division was concentrated in its area in France, but the incidence of diphtheria in certain units as they arrived was sufficiently high to demand immediate investigation. Surveys revealed a considerable number of carriers as well as clinical cases. Several units of this division had practically no cases, while among others it reached epidemic proportions.

The division moved into the Alsace sector on May 14, and continued having sporadic cases until about July 18, when the epidemic virtually subsided. The effect of this division's diphtheria is shown in the admission rate for the American Expeditionary Forces during the spring of 1918. (See Table 34.)

The 35th Division had a similar experience to that of the 32d, but less alarming. There were, however, a sufficient number of scattered cases constantly present to demand attention from June to September, 1918. The division left Camp Doniphan about the time the epidemic, previously mentioned, was subsiding. Its subsequent diphtheria indicates, as might be expected, that carriers were present throughout the organization. The disease was quite prevalent during the ocean voyage, and while in England 27 scattered cases were reported for the week ending May 29. The division moved shortly after this date, and on June 5 entrained in France for the American area. Forty-eight hours of close contact followed, and a week later there was a sharp rise in diphtheria admissions. The division finally reached its sector in the Vosges Mountains, and troops were distributed in billets and dugouts. There was less opportunity in this situation for contact and spread, and the morbidity rate declined.

During this same period a field laboratory was assigned to the division, and all contacts were cultured and the Schick test was made on them. The resultant weeding out of carriers, active and passive, was undoubtedly the deciding factor in preventing an epidemic in the organization.

The concentration of American forces for the St. Mihiel and the Meuse-Argonne operations found diphtheria well controlled and no longer a cause for alarm, but now the hospital centers were beginning to feel its presence.2


244

IN HOSPITAL CENTERS

The first hospital center to report an undue prevalence was that at Mesves. One of its units, Base Hospital No. 54, found during the month of October, 1918, that 1 per cent of its admissions was due to diphtheria, and several cases appeared among the hospital personnel. During the first two weeks of November, 1918, 34 cases appeared in the center personnel and 50 per cent were among those on duty at Base Hospital No. 54. The diphtheria prevalence occurred during the last three months of the year, when hospitals were badly overcrowded, the center under discussion averaging 18,000 patients.

In the other centers, the disease was much less prevalent than at Mesves, though quite a number of cases occurred among patients and personnel. Base Hospitals Nos. 25, 26, and 49, Allerey center, reported a number of nurses and orderlies as carriers who had been diagnosed carriers in the United States.

PATHOLOGY

In the vast majority of instances during the World War the characteristic lesion, the false membrane, was located on the fauces. Its extension into the larynx, trachea, and bronchi occurred, although not frequently.

Other changes occurred due to the absorption of diphtheria toxin or mixed infection. An analysis of 20 protocols on file in the Army Medical Museum, Washington, D. C., obtained from diphtheria cases autopsied during the World War, show the following pathological processes: Pleurisy, 5; laryngeal diphtheria or ulceration, 14; tracheal diphtheria, 9; extension into the bronchi, 5; pneumonia, 15; endocarditis, 2; myocarditis, 9; pericarditis, 5; nephritis, 6; hydrothorax, 1; fatty degeneration of the heart muscle, 3; basilar edema, 1; meningitis, 1; gangrene of the tonsils, 1; edema of the glottis, 2; acute splenitis, 7; pneumothorax, 1; bullous emphysema, 2; cloudy swelling of the liver, 8, of the kidney 7, and of the heart, 5; petechial hemorrhage, 4; evidences of gassing, 3; septicemia, 6; urticaria, 1. The blood was examined for diphtheria bacilli four times, all of which were negative. Duration of the disease after admission to hospital varied from 1 to 19 days, with an average of 5.3 days. The cases of longer duration, generally speaking, showed heart involvement.

Among 4,500 autopsy reports after pneumonia, the diphtheria bacillus was recovered in five instances, once from the bronchus and four times from the consolidated lung. Among 13,246 autopsies in the American Expeditionary Forces, 26 were on bodies of diphtheritic cases. A study of these protocols showed that 12 cases died during the acute stage of the disease. Of the others, 11 died from later complications or contributory causes.

SYMPTOMS

Types of the disease by location of the membrane are: Faucial, nasal, laryngeal, bronchial, and wound diphtheria. The records of the War Department do not permit of analysis for the total Army by such types; however, the vast majority of the cases were faucial; for example, at Camp Custer, Mich.,3 among 55 cases the membrane was situated as follows: Pharynx, 4;


245

tonsils, 41; tonsils and pharynx, 10; pharynx and larynx, 1; nose, 1. That cases of laryngeal diphtheria, and extension of the process into the trachea, bronchi, and even into the lung tissue itself, occurred is shown by reports of tracheotomy and autopsy protocols; however, the exact number of such cases in the Army is not known. In the severely gassed, pseudo membranes often occurred in the bronchi and trachea which masked the diagnosis of diphtheria.

Depending upon the severity of the disease, diphtheria is arbitrarily divided into the following types: Mild, moderately severe, severe, and malignant. This classification was used by the Army during the World War as a basis upon which to determine the antitoxin dosage. Figures, by types, are not available, but numerous reports, at home and abroad, indicate that the disease in epidemic form was relatively mild, and that though the more severe types occurred, they were in the minority.

COMPLICATIONS, SEQUELĘ, AND CONCURRENT DISEASES

Complications and sequelę constitute important phases in the clinical course of diphtheria. Among the total 10,909 primary admissions, 2,439 complications were reported, with 107 deaths. The total number of deaths credited to diphtheria among primary admissions is 177. No explanation, other than diphtheria, is found for the cause of death among the remaining 70 cases. The case mortality for the total Army was 1.62 per cent.

The most important early complication was pneumonia. This complication is a frequent cause of death, more especially in the laryngeal form of diphtheria. Usually, it is due to a secondary infection by the pneumococcus or pus organisms. In 162 cases pneumonia was reported as a complication of diphtheria, as follows: Bronchopneumonia, 61; lobar pneumonia, 101. The death rate, however, was far greater among the former. There were 10 deaths, or 9.9 per cent, among the lobar cases and 27, or 44.2 per cent, among the bronchopneumonia cases.

Perhaps the next most important complications were those involving the heart. Of 21 clinical histories of diphtheria on file in the Surgeon General's Office, the cause of death in 4 cases was attributed to pericarditis, in 2, to myocarditis, and in 1 to heart block. The average time in hospital before death was 7 days for cases with pericarditis, 6 days for those with myocarditis, and 6 days for those with heart block.

Neal and Sutton,2 studying diphtheria in the American Expeditionary Forces, attributed the myocarditis, cardiac paralysis, post-diphtheritic optic paralysis, laryngeal paralysis, and other nerve affections, as well as prolonged convalescence, to inadequate methods of treatment. The clinical histories of 21 men discharged from the service on account of disability following diphtheria show disability to have been due to mitral disease in 2 cases and myocarditis in 1. Tachycardia was noted in 25 of the primary admissions and neurocirculatory asthenia among 14. Among cases in which diphtheria was a concurrent disease, pericarditis was noted in 1, aortic insufficiency in 2, mitral insufficiency in 7, mitral stenosis in 3, myocarditis in 7, tachycardia in 2, and neurocirculatory asthenia in 6.


246

Among 47 protocols of fatal cases of diphtheria in the Army during the World War, laryngeal paralysis was a cause of death in 5. Of 21 cases discharged from the service on account of disability following diphtheria, there were 11 instances with paralysis of the upper extremity and 12 of the lower. Optic neuritis was a cause of discharge for disability in 9 cases. The cases with paralysis of the extremities also had laryngeal paralysis in 3 instances. One case was discharged from the service on account of facial paralysis and one each for the following conditions: Otitis interna, myocarditis, psychasthenia, and paralysis of deglutition. Among the 2,439 complications of the cases of diphtheria in the Army, paraplegia was present in 3, and other paralyses in 14 cases. Neuritis (without location) was present in 14 instances. No cases of hemiplegia were reported.

Nephritis was an uncommon complication. It was reported in 20 cases, 8 of which were acute and 12 chronic nephritis; that is, 0.81 per cent of the total complications. Among the nephritides there were 4 deaths, 3 of which followed the acute form.

Meningitis is a rare complication. During the war, five cases of meningitis were reported among primary admissions for diphtheria, 2 of which were of the epidemic type. The Klebs-Loeffler bacillus was not recovered from the cerebrospinal system in any of these cases.

Occurrence of diphtheria with the exanthemata is well known and at times offers difficult differentiation, particularly in some cases of scarlet fever. Occurrence with the most important exanthematous diseases during the war was as follows:

Disease

Primary admissions


Complicating diphtheria


Cases

Deaths

Measles

98,225

23

0

Scarlet fever

11,675

64

1

Chicken pox

1,757

5

0

German measles

17,378

4

1

Mumps

230,356

90

1


Total

359,391

186

3


DIAGNOSIS

The diagnosis of a typical faucial case is not difficult. The presence of a membrane in the throat of a patient acutely sick should immediately suggest diphtheria, and the case should be observed and dealt with accordingly until this tentative diagnosis has been confirmed by clinical and laboratory means. The onset of diphtheria is acute; locally there is usually a membrane, and the patient is suffering from an acute toxemia. However, other organisms are capable of producing false membranes-pneumococcus, streptococcus, bacillus of Friedlander, and Bacillus pyocyaneus. Rarely in diphtheria no membrane is formed. In practice the diagnosis of diphtheria is justifiable, provided the patient is acutely sick, suffering from a membranous sore throat, the microscopical examination of which reveals the presence of an organism morpho-


247

logically similar to the Klebs-Loeffler bacillus. If the patient has no constitutional symptoms, although diphtheria bacilli are found in the exudates, he is a carrier of a virulent or an avirulent strain, and clinically the case is not one of diphtheria. Theoretically, in order to establish a diagnosis of diphtheria, the patient must have local and general signs of the disease, the diphtheria bacillus must have been isolated from the local lesion in pure culture, it must have been proved to be virulent, and the case must have responded to antitoxin. In practice, virulence tests are reserved for carriers, and antitoxin is used for therapeutic or prophylactic and not for diagnostic purposes on man.

Although the diphtheria bacillus is abundantly present in the local lesion, carelessly taken smears may fail to reveal them; therefore, cultures should be taken with care and from the most suspicious area. Dependence can not be placed upon one negative culture.

Early diagnosis is of the greatest importance, not only for treatment, but in prevention as well. Too much emphasis can not be placed on this, since it was noted during the war, especially in the American Expeditionary Forces, that battalion and regimental surgeons occasionally were reluctant to make a clinical diagnosis of diphtheria;2 furthermore, some cases occurred on transports returning to the United States where late diagnosis was made and the cases terminated fatally on the day of, or the day after, debarkation in the United States.

Differential diagnosis between diphtheria and follicular tonsillitis, Vincent's angina, scarlet fever, streptococcic sore throat, peritonsillar abscess, and syphilitic ulceration of the mouth is important. In addition to these, cases of retropharyngeal abscess, phlegmon of the glottis, and severe gassing must be carefully examined in order to differentiate from laryngeal diphtheria. Diagnosis based upon careful physical examination and bacteriological examination is possible. In the above-mentioned conditions clinical examination alone may not furnish sufficient data for differential purposes. The fact must also be borne in mind that diphtheria may be engrafted upon one or the other of these conditions, or the case may be in reality a diphtheria carrier and clinically suffering from some other condition. Therefore, a correct diagnosis can be made only by a careful analysis of the physical findings in conjunction with the laboratory report.

During the war, severely gassed cases in whom laryngeal fibrino-purulent membranes were formed strongly resembled diphtheria. Medical officers serving overseas often remarked on the difficulty in differential diagnosis from diphtheria. The membrane in gassed cases, according to Barron and Bigelow,4 covered the lining of the larynx and trachea and extended from the epiglottis down into the bronchi and bronchioles. The tissues of the ventricles and vocal cords were at times markedly edematous, producing voice changes and mechanical obstructive breathing. This membrane rarely extended up into the larynx or over the tonsils; but nearly all of the serious cases of diphtheria had severe laryngeal manifestations, so that even at autopsy it necessitated close scrutiny to differentiate between laryngeal diphtheria and laryngitis and tracheitis following gassing. Besides, diphtheria was occasionally superimposed upon laryngitis following gassing.


248

CONTROL AND PREVENTIVE MEASURES

The most important measures for control and prevention of diphtheria are early recognition of cases and carriers and their proper isolation. Frequent inspections of men with sore throat, and culturing them will detect the cases. Not infrequently, cases occur where the symptoms are mild and the throat presents a beefy red appearance with but little membrane. Upon careful examination, pinhead-sized patches may be seen. Such cases usually have an elevated temperature, and are important in the spread of the disease. The wholesale culturing and administration of antitoxin to all those in mediate or immediate contact is a thing of the past in dealing with masses of soldiers. The control of diphtheria is principally the detection and control of diptheria carriers. Nichols5 makes the statement that in theory the detection and management of carriers have been carried almost to perfection, but in practice the system breaks down because the number of men exposed and the number susceptible are large. Since laboratory and clinical facilities are usually limited, only a certain number of cultures can be examined daily, and a much smaller number of virulence tests made. Furthermore, a limited number of Schick tests can be made daily and several days of observation are needed, while only a few persons can be quarantined and held under observation. The result is, the bacteriological plan of attack fails and common sense must govern. Clinical cases are to be considered first, and as much carrier work done as is feasible.5

The Surgeon General, on January 1, 1918, outlined the procedure to be followed in the case of diphtheria.6 These instructions were briefly as follows: Strict isolation was to be instituted. Male attendants were to be segregated and not allowed to eat or sleep with other members of the medical detachment. Nurses were to be provided with special quarters and messing facilities. When on duty in the wards, all female nurses, male attendants, and medical officers were to wear operating gowns, caps, and gauze masks over the nose and mouth; the hands were to be thoroughly washed and disinfected after coming off duty and before leaving the ward. Cultures were to be taken every fourth day from the personnel on duty in diphtheria wards, and no nurse, officer, or enlisted man was to be assigned to other duty until negative cultures were obtained. The bedding, clothing, etc., of patients and the gowns and caps of attendants were to be thoroughly disinfected by steam or chemicals before going to the laundry; nasal and oral discharges of patients were to be disinfected or burned; dishes, etc., were to be sterilized before being returned to the general kitchen. Diphtheria convalescents and carriers were not to be returned to duty until three consecutive negative cultures, taken at intervals of from three to six days, were obtained. Diphtheria carriers were not to be segregated in the same room with men sick with diphtheria, but in a suitable segregation ward, camp, or barrack. In addition the Schick test was to be applied to nurses and male attendants, and those not immune were to be immunized.

Diphtheria patients were invariably hospitalized; also some of the carriers. When in hospital, they were assigned to special wards where cubicles and masks were used. Weaver7 claimed that, coincident with the use of the mask, there was an absence of diphtheria and diphtheria carriers among the physicians and nurses of his hospital and only a limited amount of throat infection. At Camp


249

Sherman, Ohio, before the days of universal masking, it was difficult to obtain a sufficient number of negative cultures of both diphtheria and meningitis patients to permit their release from hospital.8 At Camp Grant, Ill., experiments were conducted with the mask in contagious wards, and it was concluded that this was a valuable agent in preventing cross infection.9 Haller and Colwell10 conducted extensive experiments with varying layers of gauze possessing different-sized fibers and mesh, and showed that about six layers of ordinary gauze should be used. Barron and Bigelow,4 stated that it was impracticable, of course, to mask all of the 16,000 individuals in the hospital center where they worked, though one hospital of the center tried masking its entire personnel. Cubicles were recommended by them to supplement the masks of the patients, since few could sleep with the mask in place. The original mask had two layers of gauze with a mesh of 14 to 16. It was recommended by them that two such masks be worn, since two thicknesses were insufficient. The personal cooperation of the patients was held to be absolutely essential to individual quarantine.

The following thorough procedure was adopted at Camp Sherman, Ohio, in the control and prevention of diphtheria there:8

(a) Procedures adopted in line organizations after diagnosis of a case:

Detection of one or two carriers does not call for quarantine.
All contacts of the company are segregated (intimate contacts).
All contacts are Schicked, cultured (nose and throat), and masked.
Transfer all carriers to hospital for observation and treatment and immunize all those showing positive Schick tests.

(b) Procedure in wards where diphtheria appears:

Where the patient is able to be transferred-

Transfer the patient to the diphtheria ward and do not institute quarantine.
Examine all close contacts by culture and Schick testing.
Mask all personnel and patients of the ward.
No patients will be transferred to other wards until the culture is negative.
If a case develops among the carriers, then reculture the entire ward.
Give prophylactic serum to all with positive skin tests.

If the patient is too ill to be transferred-

Quarantine the entire ward and place the patient in a single room of the ward.
Culture and Schick test the entire ward and mask all patients and personnel.
Transfer all detected carriers to the carrier ward, if possible; if not, place them in cubicles.
Repeat the culturing at two-day intervals.
When the patient's condition permits, transfer him to the diphtheria ward.
Quarantine is lifted when two negative cultures are received.

Procedure among suspects sent to hospital-

Mask them on entering the ambulance and hold under observation in an observation ward until a diagnosis is made and then make the transfer.

(c) Procedure in diphtheria and diphtheria-carrier wards:

At all times quarantined, cubicle the patients and mask the personnel.
Keep patients, convalescents, contacts, and carriers segregated by groups.

Several hospitals found it advisable to culture patients on admission, notably the hospitals at the port of embarkation, Hoboken, N. J.11

Although toxin-antitoxin mixtures were thought of during the war as a prophylactic measure, this means of conferring immunity was used to a very limited extent. It was not considered a practical war measure on account of the time required for administration and to establish immunity.


250

TREATMENT

Laryngeal diphtheria, cases seen late for the first time in treatment, and those occurring as a complication of an exanthem, should be regarded as severe and treated accordingly. In severe cases, suspected of being diphtheritic, it is better to give antitoxin and not await the results of laboratory reports, as valuable time may be lost. Cases of death due to anaphylactic shock are so rare that possible death from this cause does not justify withholding antitoxin, even intravenously, where the severity of the disease warrants its administration. However, in cases known to be sensitive to horse serum, desensitization may be attempted. The favorite dose of antitoxin used in the Army was 20,000 units, injected, as one dose, into the buttock. There is no record of desensitization having been used before giving serum during the war. If hypersensitiveness to serum is feared, an hypodermic of adrenalin should be available for immediate injection. This precaution was taken by many medical officers.

A study of many World War protocols shows that antitoxin was often repeated; for example, in one case, in which death occurred 2 days after admission to hospital, 4 injections of 20,000 units each were given, 2 subcutaneously and 2 intravenously. In another, where tracheotomy was performed immediately on admission to hospital, 30,000 units were given intravenously. As stated above, several cases were transferred from transports, upon arrival in the United States, and died soon after debarkation from laryngeal diphtheria. In some of these cases 50,000 units or more were given.

Tracheotomy was not an uncommon form of treatment in laryngeal diphtheria in the Army. The low operation was the one of preference. However, so far as the available data show, all cases died; these cases were seen late and irreparable damage was done before treatment was commenced.

The O'Dwyer intubation sets were freely distributed during the war, but there is no record of intubation having been performed.

As regards the treatment of serum sickness in diphtheria, this differs in no way from that occurring in any other disease. It usually appears a week or 10 days after serum administration and responds immediately to hypodermic use of adrenalin. Since this response is of short duration, however, the intense itching is relieved only temporarily; therefore a saline purgative should be given, which usually reduces the intensity of symptoms. This condition is of short duration and commonly borne by soldiers without treatment. There is no discoverable record of sudden death occurring in the Army during the war following the use of serum in any form.


251

TABLE 36.-Diphtheria carriers. Admissions, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919, inclusive, absolute numbers and annual ratios per 1,000

 

Total mean annual strengths


Admissions

Discharges for disability

Days lost


Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

 

noneffective ratios
 per 1,000 strength

Total officers and enlisted men, including native troops

4,128,479

5,043

1.22

9

0

98,579

0.07

Total officers and enlisted men, American troops

4,092,457

5,041

1.23

9

0

98,383

.07

Total officers

206,382

112

.54

---

---

1,163

.02

Total American troops:

 

 

 

 

 

 

 

    

White

3,599,527

4,634

1.29

8

0

91,147

.07

    

Colored

286,548

99

.35

---

---

2,127

.02

    

Color not stated

---

196

---

1

---

4,126

---

         

Total

3,886,075

4,929

1.27

9

0

97,400

.07

Total native troops (enlisted)

36,022

2

.06

---

---

16

.00

Total Army in the United States (including Alaska):

 

 

 

 

 

 

 

    

Officers

124,266

80

.64

---

---

665

.01

      

White enlisted

1,965,297

2,957

1.50

8

0

49,235

.07

      

Colored enlisted

145,826

76

.52

---

---

1,264

.02

        

Total enlisted

2,111,123

3,033

1.44

8

0

50,499

.07

        

Total officers and men

2,235,389

3,113

1.39

8

0

51,164

.06

U.S. Army in Europe, excluding Russia:

 

 

 

 

 

 

 

    

Officers

73,728

32

.43

---

---

498

.02

White enlisted

1,469,656

1,661

1.13

---

---

41,624

.08

    

Colored enlisted

122,412

22

.18

---

---

848

.02

    

Color not stated

---

195

---

1

---

4,116

---

         

Total enlisted

1,592,068

1,878

1.18

1

0

46,588

.08

         

Total officers and men

1,665,796

1,910

1.15

1

0

47,086

.08

U.S. Army in Philippines Islands:

 

 

 

 

 

 

 

    

White enlisted

16,995

1

.06

---

---

8

.00

    

Colored enlisted

4,456

---

---

---

---

14

.01

         

Total enlisted

21,451

1

.05

---

---

22

.00

U.S. Army in other countries:

 

 

 

 

 

 

 

    

White enlisteda

---

10

---

---

---

170

---

    

Color not stated

---

1

---

---

---

10

---

         

Total

14,232

11

.77

---

---

180

.03

Transports:

 

 

 

 

 

 

 

   

White enlisted

97,498

5

.05

---

---

110

.00

    

Colored enlisted

10,535

1

.09

---

---

1

.00

         

Total

108,033

6

.06

---

---

111

.00

Native troops enlisted: Philippine Scouts

18,576

2

.11

---

---

16

.00

aSeparate strength of white and colored not available.


252

CARRIERS

Only carriers who were admitted to hospital were reported to the War Department; therefore no record was made of those kept in quarantine areas except when under hospital jurisdiction. This being so, it is impossible to estimate the number of carriers detected in the Army during the World War, since various camps used their own methods of control. Table 36 shows the number of primary admissions to hospital for diphtheria carriers. There were 5,043 such admissions for the total Army, the total mean annual strength being 4,128,479 men. The ratio per 1,000 per annum was 1.22. Officers contributed 112 primary admissions, a ratio of 0.54, and enlisted men the remaining 4,929, which gave an annual admission ratio per 1,000 strength of 1.27 for the latter. The carrier state was not common among colored troops; only 99 primary admissions were reported for colored troops against 4,634 for white troops. The ratios per 1,000 were 0.35 and 1.29, respectively. The number of carriers among native enlisted troops was negligible, there being but two reported.

In the United States there were 3,113 primary admissions for the Army, with a ratio of 1.39 per 1,000 per annum; in the American Expeditionary Forces there were 1,910, with a ratio of 1.15. Despite these figures, it is not believed that there were more carriers among the troops in the United States than in Europe. Culturing was as extensively carried out abroad as in the United States, but the difference essentially is, more carriers were admitted to hospital at home than abroad. This was primarily due to the fact that relatively more bed space was available in the hospitals in the United States than in the American Expeditionary Forces. Carriers, not being sick, could be cared for as well in isolation camps as in hospital. This method was used extensively abroad. Carriers undoubtedly existed on transports, but it was neither practicable nor advisable to undertake any extended search for their detection. There were but six primary admissions on transports for carrier state.

As would be expected, there were no deaths from this cause. Nine cases were discharged from the service for disability on account of a chronic carrier state, eight of which were among white enlisted men and one color not stated.

Noneffectiveness caused by carriers was of considerable importance. For primary admissions to hospitals, Table 36 shows a loss of 98,579 days from duty, giving a noneffective ratio per 1,000 per annum of 0.07. Of the total number of days lost, white enlisted men where responsible for 91,147 days and colored 2,127. The remaining days were among soldiers where color was not stated. Time lost in the United States amounted to 51,164 days and in Europe to 47,086 days. The noneffective ratio in the United States was 0.06 and in Europe 0.08. In other words, cases admitted to hospital in the American Expeditionary Forces remained absent from duty over a longer period than for the primary admissions in the United States. The average number of days of hospitalization per case in the United States was 16.43 and in Europe 24.64.

Table 37 shows primary admissions for white and colored troops, respectively, in the United States and Europe, by months of occurrence; also the ratios per 1,000 per annum. As before stated, it is seen from this table that the number of cases reported was greater in the United States than in Europe; however, during the latter half of 1918, and for a like period in 1919, the conditions were reversed. This is accounted for by the increase in the diphtheria rate for the army of occupation on the Rhine.


253

TABLE 37.-Diphtheria carriers. Admissions, by months, white and colored enlisted men, United States and Europe, April 1, 1917, to December 31, 1919, absolute numbers and ratios per 1,000

The number of carriers reported by months shows a distinct seasonal occurrence, which reached its height during the colder months of the year. This is not true in so far as colored troops were concerned, among whom the cases reported were only sporadic. The trend is better brought out by the reports of primary admissions of carriers in the United States.

In addition to the 5,043 primary admissions, the carrier state was reported 2,359 times as a concurrent condition. This makes a total of 7,402 carriers reported as patients. It is not believed, however, that 2,359 represents the total number of carriers detected among patients during extensive outbreaks of diphtheria in our large hospital centers oversea; numerous carriers were detected, the rush of work preventing recording all such cases.


254

At Camp Custer, Mich., Blanton and Burhans3 found 148 carriers among 8,236 soldiers examined, or 1.8 per cent. McCord, Friedlander, and Walker8 found 89 contact carriers among 3,215 soldiers at Camp Sherman, Ohio, or 2.76 per cent. Keefer, Friedberg, and Aronson1 reported 686 carriers among about 30,000 men cultured at Camp Doniphan. The most extensive report on the detection of carriers is that of Schorer and Ruddock11 from the embarkation and debarkation hospitals, New York City. There, on account of the extensive occurrence of diphtheria, routine culturing of all patients admitted to hospital was deemed necessary. Table 38 shows the results of some 50,000 admissions of soldier patients arriving on transports at this port.

TABLE 38.-Results of cultures for the detection of diphtheria bacilli among soldiers arrivingat the port of Hoboken on transports, December, 1918, to May, 1919

Month


Debarkation Hospital No. 3

Debarkation Hospital 
No. 5

Debarkation Hospital 
No. 2

Embarkation Hospital 
No. 4


Patients

Positive

Per cent

Patients

Positive

Per
cent

Patients

Positive

Per
cent

Patients

Positive

Per
cent

December

4,482

34

.76

810

14

1.73

2,261

60

2.65

384

2

0.52

January

2,958

37

1.22

1,442

19

1.32

2,033

59

2.41

278

2

.72

February

3,198

51

1.59

2,958

45

1.52

1,128

17

1.51

425

1

.24

March

5,651

70

1.23

5,473

61

1.11

1,108

5

.45

294

1

.34

April

8,520

81

.95

4,047

32

.79

---

---

---

438

1

.23

May

2,378

19

.80

---

---

---

---

---

---

229

1

.44

    


     Total

27,187

292

1.07

14,730

171

1.15

6,530

141

2.16

2,048

8

.39

Grand total: Patients, 50,495; positive, 612; per cent, 1.21

Table 38 shows that the percentage of positive cultures varied from 0.39 to 2.16. Debarkation Hospital No. 2 served largely as a contagious hospital, Embarkation Hospital No. 4 for officers and nurses, while Debarkation Hospitals Nos. 3 and 5 were used for general enlisted men's debarkation hospitals. The percentage for December, 1918, and January, February, and March, 1919, was higher than during the following April and May. While 1.2 per cent of positive cultures is not high, yet the actual number, 612, is large when the short period of time and the actual number of exposures are considered. Table 39 shows the relationship between carriers and clinical cases in Debarkation Hospital No. 3.

TABLE 39.- Diphtheria carriers and clinical cases of diphtheria, relative occurrence, at Debarkation Hospital No. 3, New York, December, 1918, to May, 1919


Month

Admissions (total)

Carriers

Clinical cases

1918:

 

 

 

    

December

4,482

34

2

1919:

 

 

 

    

January

2,958

37

13

    

February

3,198

51

20

    

March

5,651

70

30

    

April

8,520

81

17

    

May 1-15

2,378

19

15

In the American Expeditionary Forces, as well as in the United States, the diphtheria carrier was a serious problem in preventive medicine; however,


255

routine culturing of line organizations was not considered practical or necessary. Upon the appearance of diphtheria, contacts were examined for the detection of carriers. Messmates, soldiers of the same sleeping quarters (more especially those whose beds were adjacent), and members of drill squads were considered contacts for quarantine and culture purposes. The search for carriers in hospitals was usually confined to patients and personnel of the ward where cases occurred; but in some instances the disease was so widespread that it necessitated examination of many wards. Reappearance of cases necessitated a second, or further, culturing for carriers. In Base Hospitals Nos. 25, 26, and 45 of the Allerey hospital center, several nurses and enlisted men of the Medical Department were detected as carriers who were known to be carriers in the United States before departure for overseas, but had been released upon the report of three negative cultures.2 In Base Hospital No. 25, 75 carriers were found, 331/3 per cent of whom gave histories of having been gassed. Since the incubator space was limited to 2,000 cultures per day, entire hospital centers were not cultured. It was remarked that it would require about eight days to culture the population of the Allerey hospital center, which approximated 16,000 persons.2 Such delay would have resulted in the loss of much of the benefit of extensive control measures. Some 13,000 cultures were made on selected cases. Carriers in the Savenay hospital center offered the same problem of control.2

Direct or indirect contact with one harboring the organism is necessary for the development of a carrier. If the strain with which the individual becomes infected is an avirulent one, or if virulent and the individual is immune, a carrier state results. Enlarged or diseased tonsils have been shown to harbor the germs with great tenacity. The presence of excessive lymphoid tissue in the nasopharynx, atrophic rhinitis, hypertrophied turbinates, deflected nasal septum, or any chronic condition that interferes with nasal ventilation predisposes the individual. Empyema of the accessory nasal sinuses and open suppurating wounds of all kinds, at times, show the presence of virulent or avirulent diphtheria bacilli. Like the disease itself, diphtheria carriers are more common during the colder months when respiratory diseases are most prevalent. Judging from our experience during the World War, carriers are much more common. among white persons of the soldier age than among colored. Weaver and Murchie12 cultured the hands of internes and nurses, also door knobs of the hospital, for the purpose of showing what part they played in the spread of diphtheria. Hemolytic streptococci were also looked for during these examinations. The technique was that commonly used in isolating these organisms; virulence and antitoxic immunization tests were also used. Of the persons examined, who came in contact with diphtheria patients, a total of 268 examinations were made by taking smears from under the fingernails and from the palmar surface of the right index finger. Of these 9.3 per cent showed the Streptococcus hemolyticus and 3 per cent the diphtheria bacillus. Of 45 nurses, 35.6 per cent showed the streptococcus and 13.3 per cent the diphtheria bacillus. Among 51 cultures made from graduate nurses, specially trained in the care of diphtheria patients and actually engaged in this work, 2 per cent showed the Streptococcus hemolyticus and none the diphtheria bacillus. Of 45 cultures made from 3 internes,


256

15.6 per cent yielded the Streptococcus hemolyticus and 6.7 per cent the diphtheria bacillus. Each of the three internes showed the diphtheria bacillus on one occasion after ordinary washing. It was recovered after autopsy on a diphtheria case where no rubber gloves were worn. Cultures were also made from the door knobs in 137 instances. The Streptococcus hemolyticus was found in 5.8 per cent and the diphtheria bacillus in 4.4 per cent. All of the above examinations were made after ordinary washing with soap and water. Barron and Bigelow4 made 522 cultures from the hands of patients, and from fomites in wards containing diphtheria as well as in wards where no diphtheria was reported. This was done for the purpose of showing the value and danger of the face mask in the spread of diphtheria bacilli. The following is a summary of this work:


Exposed wards:

Per cent

Exposed wards-Continued.

Per cent

     Typical B. diptherię-

    

Atypical B. diphtherię-

              

On "masked" hands

6.3

         

On "unmasked" hands

14.9

              

On "masked" fomites

8.1

         

On "unmasked" fomites

7.4

    

Typical B. diphtherę-


Unexposed wards:

         

On "unmasked" hands

16.1

    

Atypical B. diphtherię-

         

On "unmasked" fomites

4.9

         

On "unmasked" hands

5.9

    

Atypical B. diphtherię-

         

On "unmasked" fomites

5.0

         

On "masked" hands

6.3

 

         

On "masked" fomites

11.7

"Exposed wards" were wards in which clinical cases of diphtheria or carriers were treated; "unexposed wards" were wards in which no cases of diphtheria or carriers had been found. The term "masked" means that the patient whose hands or fomites were cultured wore a mask, while "unmasked" means, conversely, that he wore no mask. Typical diphtheria bacilli were found nearly three times as often upon the hands of those not wearing masks as upon those wearing them.

TECHNIQUE OF EXAMINATION FOR CARRIERS

The detection of carriers bacteriologically requires the same technique as in the search for cases; however, the taking of specimens differs. In the former, there is usually no acute pathological process as a guide to the most probable site where the organisms may be found and found in great preponderance. In routine culturing for carriers a sterile swab is pressed and passed firmly over the faucial surfaces, particular attention being paid to the tonsils. The swab is then stroked over the surface of a blood serum slant which is incubated and later examined as in the detection of cases. Additional swabs, made from the nasal passages, increase the percentage of positive cultures. Both faucial and nasal smears may be made on the same slant. This method was used in some instances, especially at Camp Doniphan, Okla.,1 although it may be said that most medical officers were content with the faucial specimen, except in selected carriers where the carrier state became chronic and the focus of infection was sought for.

It was emphasized by medical officers repeatedly during the war that single cultures, irrespective of the technique used, would reveal only a portion of the carriers. The percentage varies between wide limits. Among healthy


257

persons of various ages, single cultures show from 1 to 30 per cent to be carriers, with an average of 3 to 4 per cent, and probably reveal less than one-half of the persons infected. As regards the pathology of chronic carriers, Nichols5 states that among incubationary carriers the bacilli are found in large numbers at the site of the common lesion; in contact carriers nothing specific is found, and among chronic convalescent carriers the tonsil is by far the most common focus of infection. Occasionally, however, the organisms are found in sinuses or in adenoid tissue. There is no local inflammatory reaction with an outpouring of exudate into the tonsillar crypts; therefore the organisms are not easily detected.

Keefer, Friedberg, and Aronson,1 reporting 294 patients at Camp Doniphan, Okla., where the tonsils were removed to relieve the carrier state, found 57 per cent positive and 43 per cent negative in cultures made from the tonsil immediately preceding the operation. Cultures of the tonsils made after tonsillectomy gave positive results in 77.2 per cent. They concluded that 22.8 per cent of the cultures were negative and emphasize the importance of not relying upon a single examination. Blood cultures were made by them from 43 contact throat carriers, 9 convalescent throat carriers, 3 wound carriers, and 2 wound cases. All were sterile except 1 and that may have been a skin contamination. Urine cultures were made from centrifugalized specimens of 26 carriers and all were negative. The feces were negative in all of 21 carriers examined. Simmons, Wearn, and Williams13 examined the blood of 25 carriers for isohemagglutinins, according to the Moss classification, with the following results: Group 1, 4 per cent; group 2, 24 per cent; group 3, 12 per cent, and group 4, 60 per cent.

Virulence is the most important factor as a guide to subsequent management. If the carrier is an early convalescent or a contact one, no virulence test is necessary, as most of these strains are virulent; but if the carrier state is a long or doubtful one, then virulence tests are indicated. As to retesting for virulence, this is not necessary, since avirulent strains never acquire virulence and virulent strains retain their virulence with great tenacity.

Although about 10 per cent of chronic carriers are found to harbor virulent organisms, those who have not been in contact with cases do not seem to be of importance. At camp Custer, Mich., among 148 carriers found, 24 strains were recovered and tested for virulence on guinea pigs.3 Of these 88 per cent were avirulent. Simmons, Wearn, and Williams,13 reporting on the virulence of 52 strains among throat and wound carriers, state that the percentage among contact throat carriers was 48.1 per cent, and from convalescent throat carriers 84.6 per cent. Blanton and Burhans3 expressed the opinion that too much reliance is probably placed on the so-called "virulence tests."

Duration of the carrier state is either short or prolonged, lasting from a few days to months or years. The average period of hospitalization for carriers, previously admitted to hospital for this condition, was 19.54 days. In the United States the average was 16.43 and in the American Expeditionary Forces, 26.04 days. When analyzed more in detail, it is seen that the duration varied between wide limits. At Camp Custer, Mich., the average number of days in hospital among 148 carriers was 11.7 days.3 At Camp Doniphan,


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Okla., it was arbitrarily assumed that the carrier state, among patients convalescing from diphtheria, commenced at the end of the third week of the disease, since the average case becomes bacteria free at that time.1 It was found that 91.3 per cent of convalescent carriers became baccillus free at the end of the second week following tonsillectomy, among 294 carriers operated upon. The length of time required for the carrier state to end in the debarkation and embarkation hospitals, New York City,11 is shown in Table 40.

TABLE 40.-Diphtheria carriers. Duration of carrier state, embarkation and debarkation hospitals, New York. Absolute numbers and average periods of hospitalization by 10-day groupings

 

Number of carriers

Period of hospitalization


Less than 10 days

10 to 20 days

20 days or longer

Grand
average
in days

Number

Per
cent


Average number of days

Number

Per
cent

Average number of days

Number

Per
cent

Average number of days

Hospital Ship O'Reilly

65

30

46.1

7.8

24

36.9

12.9

11

18.3

22.7

12.2

Debarkation Hospital No. 1

100

42

42.0

6.8

35

35.0

13.7

23

2.3

28.7

10.94

Debarkation Hospital No. 3

276

178

64.2

5.1

74

26.7

12.7

15

5.4

24.4

8.0

Debarkation Hospital No. 5

36

32

88.8

7.0

3

8.5

15.3

1

2.3

22.0

8.1

Embarkation Hospital No. 4

66

59

89.4

8.4

7

10.5

11.8

---

---

---

8.8

This table includes 543 carriers tabulated by hospital and subdivided into 3 classes as follows: Less than 10 days; 10 to 20 days; and 30 days or longer. It is seen that the averages varied from 8.0 to 12.2 days. There were some chronic carriers in all of these hospitals, but officers and nurses cleared up quickly. The majority were only temporary carriers. On the hospital ship O'Reilly only 12 per cent cleared up in 12 days or less as compared with the results of Embarkation Hospital No. 2, where, among 270 carriers, but 9 had to remain in isolation for more than 3 days.

As to the handling of diphtheria carriers, during the earlier months of the war practically all such carriers in the United States were hospitalized, their presence being looked upon with grave apprehension. As time went on, however, and space in hospitals became less available, it became the practice to isolate carriers (except incubationary and convalescent) in barracks or tent areas especially set aside for the purpose. Incubationary and convalescent carriers continued to be cared for in hospital. As soon as practicable after being quarantined, each carrier was given the Schick test. Contact and chronic carriers showing positive skin tests were immunized, generally with 1,000 units of antitoxin. In rare instances a toxin-antitoxin mixture was used. Pseudocarriers were released as soon as detected. If a carrier state was a prolonged one, it was often shortened by transfer to hospital for tonsillectomy or virulence testing. In hospitals, carriers were assigned to wards where cubicles and masks were used; in barracks, improvised cubicles were used. The quarantine of contacts was considerably shortened by the use of throat cultures and the Schick test. It was considered safe to release carriers 24 hours after all susceptibles had been immunized.


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    TREATMENT OF CARRIERS

Various chemicals were used locally to clear up carriers. Tincture of iodine seems to have been the favorite. Diphtheria antitoxin was used locally and by injection without success. The only local measure that seems to have met with general favor was tonsillectomy. At Camp Sherman, Ohio, tonsillectomy was performed on a number of cases with prompt results.8 Of the 294 carriers treated by tonsillectomny, reported by Keefer, Friedberg, and Aronson, 32 per cent had no further positive cultures, while 46.4 per cent were negative at the end of one week, and 91.3 per cent negative at the end of the second week. Striking results were seen after tonsillectomy at Camp Custer.3 The consensus of opinion of medical officers seems to have been that in chronic carriers where diphtheria bacilli were located in the tonsils, by far the best form of treatment is tonsillectomy. This method of treatment could not be expected to produce favorable results if there were foci of diphtheria bacillus infection elsewhere. Other than this, it may be said that local treatment was, in general, ineffective in relieving the carrier state.

Briefly, it may be said that carriers of avirulent organisms are harmless and attempts were made to isolate only carriers of virulent bacilli. Appropriate treatment, depending upon the kind of carrier, was given. For release from quarantine, three consecutive negative cultures, without treatment, at daily intervals, or on alternate days, were required. A long protracted isolation was not looked upon with favor unless the organism was a virulent one.

WOUND DIPHTHERIA

Diphtheria bacilli are capable of producing a false membrane in wounds. These organisms may exist alone or associated, and it appears that no variety of wound is immune. Wound diphtheria has been reported as complicating empyema wounds, chronic suppurating wounds in general, especially such as amputations, burns, bites, blisters, contusions following gunshot injuries, compound fractures. Though there is usually a false membrane, diphtheria infection has been found where no membrane was present. This, however, is the exception. There is usually a fetid, offensive odor, which, too, may be absent. All authors reporting on this subject apparently agree that the diagnosis of wound diphtheria can not be made with certainty upon clinical grounds alone; nevertheless, any unusual appearance in a surgical wound should lead to a bacteriological examination of the discharge; and if an organism is found that resembles diphtheria morphologically or culturally, virulence tests are called for. By this method it can be determined whether the wound infection is really of a diphtheritic nature or not. In the diagnosis of suspicious wounds, where cultures made from surface smears are negative, curettement should be done and smears taken from a deeper layer.

Hartsell and Morris14 reported upon 60 cases of wound diphtheria in the Army during the World War. In none of these wounds were there any systemic symptoms referable to diphtheria toxin. The clinical appearance of the wound varied; that is to say, 12 per cent showed the grayish membrane typical of diphtheria; one-half showed only a faint grayish discoloration of the granulating surfaces; about 6 per cent looked absolutely healthy and ready for


260

secondary closure. So far as could be observed, the presence of diphtheria bacilli in the wound had no effect upon healing. The Schick test was performed on 43 patients, 6 being positive. The response to treatment varied. In some cases the diphtheria bacilli disappeared 2 days after treatment, while in others they were very resistant, ranging to 49 days. By far the most efficient treatment was tincture of iodine. With this treatment, 15 cases cleared up under 48 hours, and only 11 cases remained positive longer than a week. Antitoxin, in 4 doses of 20,000 units each, was given in 4 cases, but had no effect on ridding the wound of the bacillus. Antitoxin as a wet dressing was also used in two cases without effect. Acetic acid, cauterization, and Carrel-Dakin solution were used without effect.

Keefer, Friedberg, and Aronson, reported an epidemic of wound diphtheria in two wards of the base hospital at Camp Doniphan, Okla., where rib resections had been made on account of empyema. Between March and May, 1918, 40 cases occurred. In 33 cases the diphtheria bacillus was found in the wound, while in 12 it occurred both in the throat and wound of the same individual. Simmons, Wearn, and Williams13 reported diphtheria infections with particular reference to carriers, and wound infection with diphtheria bacilli at the Walter Reed General Hospital, Washington. They reported that 42 per cent of the strains from wound carriers were very virulent, while 80 per cent of those from wound cases were very virulent. Neither morphology, fermentation reactions, nor cultural characteristics gave any indication of the degree of virulence of the organism studied.

Simmons and Bigelow,14reporting on diphtheria bacilli in postoperative empyema wounds from the laboratory of the Southern Department at Fort Sam Houston, Tex., found an organism morphologically like the diphtheria bacillus in 60 healing cases. Of the organisms isolated, 17.8 per cent were virulent for guinea pigs, and all of these strains failed to produce acid when grown on saccharose broth for eight days. However, the degree of virulence of sugar negative strains was variable. The morphologic characteristics of virulent and avirulent strains were the same and all cultures contained a mixture of Westbrook's types A, C and D with subtypes. They found no evidence of the development of specific agglutinins, precipitins, or complement fixation substances for diphtheria bacilli in the serum of infected individuals. Apparently, there is no invasion of the blood stream by the diphtheria bacillus in wound cases. All methods of treatment proved unsatisfactory, due probably to the growth of the bacilli deep in the granulations.

The extent of wound diphtheria in the American Expeditionary Forces is not known. Barron and Bigelow4 reported its presence at the Allerey hospital center, but the number of cases was not given by them. As a primary admission, wound diphtheria was not tabulated on the Army's list of diagnoses; therefore, the total number of cases can not be determined.

The specific treatment of wound diphtheria is that of faucial diphtheria. The treatment of wound carriers is as unsatisfactory as that of throat carriers. Antitoxin, both local and by injection, has been used without satisfactory results for carriers. The unsatisfactory results obtained from local treatment are probably explained by the deep situation of the bacilli. In the work of Simmons, Wearn, and Williams,13all methods of treatment proved to be unsatisfactory, and, as a rule, the carrier state continued until complete healing of the wound had taken place.


261

REFERENCES

(1) Keefer, F. R.; Friedberg, S. A.; and Aronson, J. D.: A Study of Diphtheria Carriers in a Military camp. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1206.

(2) Neal, M. P., and Sutton, A. C.: Diphtheria in the A. E. F. The Military Surgeon, Washington, 1919, xlv, No. 5, 521.

(3) Blanton, W. B. and Burhans, Chas. W.: A Report of Diphtheria at Camp Custer, Mich., from September, 1917, to March, 1919. The Journal of the American Medical Association, Chicago, lxxii, No. 19, 1355.

(4) Barron, Moses, and Bigelow, Geo. H.: Diphtheria at a Hospital Center. The Journal of Infectious Diseases, Chicago, 1919, xxv, 58.

(5) Nichols, H. J.: Carriers in Infectious Diseases. Williams and Wilkens Co., Baltimore, 1922, 72.

(6) Circular Letter, S. G. O., January 1, 1918.

(7) Weaver, Geo. H.: The Value of the Face Mask and other Measures in Prevention of Diphtheria, Meningitis, Pneumonia, etc. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 2, 76.

(8) McCord, C. P.; Friedlander, A.; and Walker, R. C.: Diphtheria and Diphtheria Carriers in Army Camps. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 4, 275.

(9) Capps, J. A.: A New Adaptation of the Face Mask in Control Contagious Disease. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13, 910.

(10) Haller, D. A., and Colwell, M. C.: The Protective Qualities of the Gauze Face Mask. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1213.

(11) Schorer, E. H., and Ruddock, A. S.: Detection of Carriers and Missed Cases of Diphtheria in Embarkation and Debarkation of Troops. The Military Surgeon, Washington, 1919, xlv, No. 3, 319.

(12) Weaver, Geo. H., and Murchie, J. T.: Contamination of the Hands and Other Objects in the Spread of Diphtheria. Observations on Secondary Infections in Hospitals for Contagious Diseases. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 26, 1921.

(13) Simmons, J. S., Wearn, J. T., Williams, O. B.: Diphtheria Infections, with Particular Reference to Carriers and to Wound Infections with B. diphtherię. The Journal of Infectious Diseases, Chicago, 1921, xxviii, 327.

(14) Hartsell, J. A., and Morris, M. L.: A Report of Sixty Cases of Wound Diphtheria. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 19, 1351.

(15) Simmons, J. S., and Bigelow, G. H.: Diphtheria Bacilli from Postoperative Empyema Wounds. The Journal of Infectious Diseases, Chicago, 1919, xxv, 219.