Diseases Caused by Bacteria
Aims C. McGuinness, M. D.
Diphtheria in World War II could not, from a
statistical point of view,
have been said to have
reached epidemic proportions in any theater of operations;
approximately 5,700 cases were
reported for the total Army between January 1942 and December
1945. Because of the serious
disability associated with the disease, however, it presented a problem
importance in the European and Mediterranean Theaters of Operations, in
the Pacific areas, and
in the India-Burma theater. There were 125 deaths, 67 of which occurred
in the European theater
in 1945. Cutaneous diphtheria attending desert sores
and tropical ulcers was a form of the
disease virtually unknown to most medical officers, even though the
desert sore of diphtheria
lead been recognized by the British for many years, both in the Middle
East 1 and in northern
India.2 The severe polyneuritides following diphtheria,
encountered especially in the
Mediterranean and European theaters, likewise were a new problem to the
United States Army
medical officers. 3 In the European
theater, diphtheria was a particular hazard to the occupation
The number of cases of diphtheria and rates per
1,000 strength per annum in the various theaters
and areas from January 1942 through December 1945 are shown in table
27. Table 28 shows
deaths and mortality rates from diphtheria during the same period.
EXPERIENCE IN THE CONTINENTAL UNITED
The United States entered World War II at a time
when the incidence of diphtheria in this
country had reached extremely low levels. In 1920, there were
approximately 150,000 cases of
diphtheria, with nearly 14,000 deaths, reported from 41 States.
In 1938, there were
approximately 30,000 cases from the entire country, with 2,600 deaths,
a reduction of about 80
percent in both numbers of cases and deaths. In only- a few
States-namely, West Virginia,
Kentucky, Tennessee, and sections of Virginia, North Carolina,
Missouri, Arkansas, Texas, and
New Mexico-were relatively high mortality rates still
1 Craig, C. McKi.: A Study of the Aetiology of the
"Desert," Septic, or Veldt Sore Amongst
European Troops: And Its Association With Faucial Diphtheria.Lancet 2:
2 Bensted, H. J.: A Limited Outbreak
of Diphtheria Exhibiting Both Cutaneous and Faucial
Lesions.J. Roy. Army M. Corps 67: 295-307, November 1936.
3 (1) Johnson, .J. W., Jr.: Infectious
MTOUSA, pts. 1 and 2.[Official record.] (2)
Sampson, 1. J.: Late Neuronitis Following Proved and Suspected
Cutaneous, Faucial, and
Wound Diphtheria. Am. J. M. Sc. 212: 432-448, October 1946.
of diphtheria in
the U. S. Army, by area and year, 1942-45
to be found. 4 For the week eliding 28 December 1940,
diphtheria in this country reached a record
low; each section of the country reported the lowest incidence in
recent years. 5 A leading
textbook of pediatrics published in late
1940 6 stated that 80 percent of urban
immune to diphtheria. Only in certain large cities and in a few rural
areas did physicians have an
opportunity to see the clinical picture with any degree of frequency.
Thus, as a whole, the
physicians of the country were complacent as to the problem and
ignorant as to the disease, and
relatively few laboratory personnel were competent in the bacteriologic
techniques required for
isolation and identification of virulent Corynebacterium diphtheriae.
In 1940, a study by Stebbins, Ingraham, and Chant
7 lent support to the theory that, with
decreasing incidence of clinical infection and the associated decrease
in the prevalence of
carriers of toxigenic C. diphtheriae,
natural immunization was materially reduced.
4 Dauer, C. C.: Geographical
Distribution of Diphtheria Mortality in the United States. Pub.
Health Rep. 55: 622-628, April 1940.
5 Prevalence of Communicable Diseases
in the United States. Pub. Health Rep. 56: 89-92, 17 Jan.
6 Holt, L. Emmett, Jr., and McIntosh,
Molt's Diseases of Infancy and Childhood. 11th
ed.New York: D. Appleton-Century, 1940, p. 1083.
7 Stebbins, E. L., Ingraham,
H. S., and Chant, H. L.: Changing Factors in Diphtheria Immunity:
Its Production and Duration. New York State J. Med.
40: 658-665, April 1940.
TABLE 28.- Deaths due
in the, U. S. Army, by area and year, 1942-45
On 10 November 1941, Lt. Comdr. (later Capt.)
D. Fothergill, MC-V(S)USNR, made a
very significant report to the medical officer in command, United
States Naval Medical School,
Washington, D. C., on a Schick-test survey at the Norfolk, Va.,
Newport, R. I., and Great Lakes, Ill, naval training stations.8
This study, which was reported subsequently by Cheever, 9
Worcester and Cheever,10 was in part prompted by the
diphtheria in Halifax, Nova
Scotia, which had reached serious levels the preceding winter; certain
significant findings in that
epidemic disclosed that over 50 percent of the cases were persons more
than 15 years of age and
that 48 percent of the population 20 years of age and over (not
previously immunized) were
found to be Scllick positive.
In the study among recruits at the Norfolk,
Newport, and Great Lakes stations, there was found
an over-all Schick-positive rate of 33.8 percent. Recruits from the New
England States showed
the highest rate (32 to 76 percent) of susceptibility, and rates for
the East and West North Central
States were almost equally as Nigh. Much lower rates (7 to 10 percent)
were found among
recruits from the South Atlantic, East South Central, and West
8 Memorandum, Lt. Comdr. L. D.
Fothergill to Medical Officer in Command, U. S. Naval
Medical School, 10 Nov. 1941, subject: Schick Test Survey at Norfolk,
Newport, and Great
Lakes Naval Training Stations.
9 Cheever, F. S.: A Schick Survey of
18,000 Naval Recruits.Am. J. Pub. Health 38: 374-377,
10 Worcester, J., and Cheever, F. S.: The Shick Status of
18,000 Young Adult Males. New
England J. Med. 240: 954-959, June 1949.
South Central States, where diphtheria still was moderately
prevalent. This study emphasized the
importance of latent or subclinical infection as a factor in the
production and maintenance of
active immunity. Fothergill's group found further that about
one-quarter of the Schick-positive
group lead a positive Maloney reaction together with a positive Schick
test and therefore could
not be immunized with toxoid without danger of serious reaction.
Fothergill's report came as a strong alert to the
Preventive Medicine Division, Office of the
Surgeon General. During the next 2 years, however, diphtheria did not
appear to present a
serious problem to United States Army troops, either in the Zone of
Interior or overseas. In late
1943, there were reports of a definite increase in diphtheria in the
civilian populations of
continental Europe, as well as reports of the presence of diphtheria to
an unexpected degree
among United States troops in the South Pacific Area. As a result of
these reports, the Preventive
Medicine Service conducted a study 11 at
Camp Ellis, Ill., and at Camp Tyson, Tenn., during the
months of February, Marcll, and April, 1944, to determine (1) what
proportion of United States
troops were susceptible to diphtheria; (2) what degree and portion of
reactions were to be
expected following the administration of diphtheria toxoid to troops;
and (3) what method might
be utilized to screen out the majority of reactors. The study was under
the over-all direction of
Lt. Col. (later Col.) Arthur P. Long, MC, Preventive Medicine Service,
and the investigations
were carried out by a team composed of Capt. (later Maj.) Emanuel B.
Schoenbach, MC, of the
Army Epidemiological Board; Dr. Paul B. Beeson, a civilian consultant
of Atlanta, Ga.; and a
technical assistant, Miss Charlotte Root.The findings are summarized as
Among 2,933 Schick-tested individuals, 44 percent
were found to have positive reactions
including 5.8 percent with combined reactions. In general, the
Northeastern and North Central
States tended to have high percentages of susceptibility and the
Southeastern States low
percentages. This paralleled Fothergill's findings among Navy recruits.
To determine the degree of reactions to
diphtheria toxoid, studies were carried out on groups of
approximately 300 men each, none of whom previously was Schick tested.
received an intracutaneous injection of 0.1 cc. fluid toxoid diluted to
contain 0.1 Lf per cubic
centimeter, and at the same time a subcutaneous injection of 0.1 cc. of
undiluted fluid toxoid.
Approximately 5 percent of the individuals receiving the toxoid
reaction test dose were
hospitalized, and 3.7 percent were confined to quarters; 15.6 percent,
while demonstrating some
untoward reactions, continued on duty. Approximately 75 percent were
retained for the 0.5 cc.
dose of toxoid. Of the 429 individuals who received 0.5 cc. of toxoid,
5.8 percent were
hospitalized, and 325 or 75.8 percent were retained for further doses.
While the number of cases of diphtheria in the
United States Army during the 2 years following
Pearl Harbor was not significant, the complacency which
11 Diphtheria Susceptibility and Immunization.
U. S. Army M. Dept. No. 76, 104-108, May
had existed in regard to this disease during the pre-Pearl Harbor
mobilization had yielded to a
realization of these three important facts:
1. A substantial percentage of United States Army
troops was susceptible to diphtheria.
2. There were indications that the disease might
become a serious threat to overseas troops.
3. The indiscriminate administration of
diphtheria toxoid in the regular dosage might be
expected to result in a relatively high proportion of reactions in
Diphtheria among troops stationed in the
continental United States never reached serious
proportions. In table 27, rates of 0.03, 0.04, and 0.04 per 1,000
average strength per annumwere
reported for the years 1942, 1943, and 1944, respectively. Cases were
scattered and special
control measures such as routine immunization never received serious
consideration. In 1945,
the rate increased to 0.07 per 1,000 average, strength per annum,
largely as a result of patients
with diphtheria arriving on transports from overseas theaters, chiefly
from the Pacific.A number
of these patients, many of whom lead cutaneous diphtheria, reached the
Hospital in San Francisco, Calif., and Moore General Hospital in
Asheville, N. C.12 This
situation led to a number of secondary cases among other patients as
well as among hospital
personnel, a significant number of the cross-infections occurring on
wards.Again, except for these special situations, diphtheria was not
all important problem in the
Zone of Interior.
EXPERIENCE IN EUROPEAN THEATER OF
the Ministry of Health in Great Britain,13
it was learned that the diphtheria
situation in the civilian population was of no particular import, that
it compared favorably with
conditions in the United States, and that the general trend of
diphtheria since 1940 had been
downward.The reported incidence of diphtheria among soldiers of the
British Army stationed in
England indicated that the rates were decidedly low.
Table 29 shows the diphtheria rates in England and
Wales for the years 1939 to 1945, inclusive.
1941, diphtheria began to increase in France,, Germany, The
Belgium, Norway, and Denmark. The year 1942 showed a substantial
increase over 1941, and
the rates and reported cases for 1943, as shown in table 30 were truly
which was available early in 1944, served as a warning that
diphtheria might be a disease
12 Memorandum, Commission on
Meningococcal Meningitis, Army Epidemiological Board, for
The Surgeon General, 6 July 1945, subject: Diphtheria Infections at
Letterman General Hospital,
San Francisco, California, and at Moore General Hospital, Asheville,
Gordon, J. E.: A History of
Medicine in the European
Theater of Operations, L .
S. Army, 1941-15. [Official record.]
TABLE 29.-Diphtheria in England and Wales, 1939-45
of appreciable importance among infections to be encountered by
invading France, the
Low Countries, and Germany.
United States Army.-The rising tide of diphtheria in
in the early 1940's, together
with the knowledge that a relatively high degree of susceptibility
existed among United States
troops,14 gave ample warning to the problems that might
forces with respect to
diphtheria at such time as they might invade the occupied countries and
Germany. On the other
hand, the diphtheria situation in the civilian population of England
was on a level with the low
rates prevailing in the United States, so that no particular difficulty
was anticipated among the
large bodies of United States troops accumulating in England during
1942, 1943, and up to the
Normandy invasion in June 1944.
As anticipated, except for a few scattered cases,
diphtheria presented no problem in the
European theater in 1942 and 1943. There were 27 cases reported for
1942 with a rate of 0.33
per 1,000 average strength per annum, and 45 cases with a lower rate of
0.17 for the year
1943.Even lower rates prevailed until November 1944 when our troops
reached the Low
Countries and the cold and wet of winter had set in. From that
time on, there was a steady
increase in cases and rates. During the first 6 months of 1945-the
final campaign of the war
against Germany-there were 1,037 cases reported with an over-all rate
of 0.76 per 1,000 per
annum and a rate of 1.05 for the month of April. Unquestionably, as was
the case in other
theaters, many uncomplicated cases passed by without recognition.
Germany surrendered on 7 May 1945, and during the
months of June and July the number of
cases of diphtheria in the Armed Forces dropped off sharply.As United
States troops began to
mingle with the civilian population of Germany, the rates again
increased, and it was soon
evident that this disease was to become one of the major hazards of
infection in the army of
14 See footnote 13, p. 171.
TABLE 30.- Incidence
of diphtheria in civilian populations of Germany and
countries in Europe, 1939-43
occupation. Rates again rose to over 0.92 per 1,000 average
strength per annum in September
1945 and from October through December were less than 3 percent.
During 1945, a total of
2,240 cases were reported in United States Army personnel.
No deaths from diphtheria occurred in the European
theater in 1942
and 1943, and none in 1944
until operations started on the Continent. During the latter half of
1944, there were five deaths
with a case fatality rate of 2 percent. In 1945, there were 2,240 cases
with 67 deaths, or a case
fatality rate of 3 percent.
While the experience of the occupation forces
after 31 December 1945 is beyond the scope of
this report, it is important to note that during 1946 diphtheria
accounted for 15.3 percent of all
deaths from disease conditions occurring in the theater and for 45.3
percent of all deaths
occurring from communicable diseases. It caused twice as many deaths
during that year as did
the primary pneumonias.15
At the request of the Chief Surgeon,
Headquarters, European Theater of Operations, and The
Surgeon General, the author accompanied by Dr. J. Howard Mueller,
consultant to the Secretary
of War and member of the Commission on Epidemiological Survey, Army
Board, made an investigation of problems of diphtheria in the military
and civilian populations
of the European theater during the period of 19 June to 18 August 1945,
inclusive.16 This survey
revealed many things which lead considerable bearing on the problems
which were to develop
among United States troops the following fall and winter.
Diphtheria. was prevalent among
civilians but not excessively in the southern part of Germany and in
Austria, the highest
incidence being found in bombed-out cities such as Munich.In the
northern cities, particularly
Berlin, Bremen, and Hamburg, the rates were high even during the summer
significant in Bremen, as well as elsewhere in Germany, that diphtheria
was now a disease of
adults, only 25 to 30 percent of the cases reported were children. With
these great reservoirs of
virulent C. diphtheriae in
the civilian population, it is obvious why, as the rules against
fraternization were relaxed, American troops in increasing numbers
contracted the disease from
their civilian contacts. Furthermore, it was very difficult to control
the disease in the urban
civilian populations which lived under conditions of extreme crowding
and poor hygiene amidst
the rubble of their bombed-out homes.
In the summer of 1945, it was recognized that
diphtheria could be acquired venereally. In an
evacuation hospital in Darmstadt, Germany, the author saw four cases of
diphtheria in men from
different units who apparently had contracted the disease from the same
prostitute. The results of
a carrier study made in April and May 1946 by Dr. Martin Frobisher,
Jr., and Dr. Franklin H.
Top, is summarized in table 31.This report is of interest in that it
15 Schulze, H. A.: Diphtheria in
the U. S. Army in Europe.ETO M. Bull. 2 (No. 6): 2-26, June
16 Letter, Dr. J. H. Mueller and Lt. Col. A. C.
MC, to The Surgeon General, 15
Aug. 1945, subject: Survey of Problems of Diphtheria. in ETO-Summary
up the high carrier rates among German adult females in the Frankfurt
region. Drs. Frobisher and
Top, in a study of the age and sex distribution of diphtheria in three
German population centers
in September, October, and November, 1946, showed that almost twice as
many cases were
occurring in females as in males.17
The problem of management of carriers and steps
taken to control diphtheria in the European
theater is discussed in subsequent sections.
Army personnel and German civiliansin the
European theater, April and May 1946
EXPERIENCE IN NORTH AFRICA, THE MIDDLE
EAST, AND ITALY
Diphtheria had for years been known to be present in
the civilian populations of the North
African countries, with a moderate amount of the disease in the British
Army, as already
mentioned.18 Statistics available
(table 32) indicate that the amount of the disease among the
civilian populations remained at a relatively constant level during the
years in which United
States forces were engaged in the North African and Middle East
campaigns, although these
figures cannot be considered entirely reliable.
17(1) See footnote 15, p. 174.(2) Preliminary
Report, Diphtheria Commission, March-May 1946,
by Dr. M. Frobisher, Jr., and Dr. F. H. Top.
18 See footnote 1, p. 167.
TABLE 32.- Incidence
of diphtheria in civilian populations in North African countries,
The situation in Italy was not clear
early in the
war, but figures now
available are significant in
that the total number of reported cases of diphtheria reached an
11-year low of 21,161 in 1941
and rose to 30,099, an 11-year high, in 1942.19
Army.-The Mediterranean theater (including North
Africa) reported the highest
rate for diphtheria during 1942-45. The rate for the Middle East
theater, however, was one of the
lowest recorded. During this period, there were 1,087 cases in the
Mediterranean theater with the
annual rate per 1,000 average strength being 0.73. Comparable data for
the Middle East theater
were 45 cases and an annual rate of 0.31 per 1,000 average strength
The Theater Surgeon, NATOUSA (North African
Theater of Operations,
United States Army),
reported in 1943 that mumps, measles, diphtheria, Vincent's infections,
rheumatic fever, scarlet fever, chickenpox, smallpox, and whooping
cough accounted for 1,678
(2.62 percent) of the total respiratory diseases. The only feature of
this small group of cases is
that they occurred predominantly in the early months of the year.
Actually, as stated previously, there were only
45 cases of
diphtheria reported from Africa and
the Middle East from 1942 to 1945 (table 27). With the invasion and
occupation of Sicily and
the Italian mainland in the summer and fall of 1943, there developed a
awareness of the diphtheria problem. The Essential Technical Medical
Data from NATOUSA
for November 1943 called attention to the fact that diphtheria was
slowly but definitely
increasing and pointed out that patients were slow to arrive in medical
Essential Medical Technical Data from NATOUSA for October 1943 reported
20 cases of
diphtheria among prisoners of war admitted to the 56th Station Hospital
and the 16th Evacuation
centrale di Statistica del Regno d'Italia: Annuairo
Statistico Italiano, Anno 1936-XIV; Anno 1937-XV; Anno 1938-XVI.(2)
Istituto Superiore di Sanita: Andamento nel 1941
Dille Malattie Infettive e Diffusive Sogette a Denunzia Obbligatoria,
Ibid: nel 1942, 1947, p. 67.
20Annual Report, Medical Section,
NATOUSA, 1943, p.
the months of June, July, and August of that year. Brig. Gen.
Frederick A. Blesse, Surgeon,
NATOUSA, issued Circular Letter No. 37, 2 October 1943, extending a
warning to medical
officers to be on the alert for the disease and pointing out the
possibility that wound and anal
diphtheria might occur. It is obvious, in retrospect, that many
complications were never diagnosed.
The year 1944 showed a sharp increase in the
number of diphtheria
cases in the Mediterranean
theater-628 cases and a rate of 0.97 per 1,000 per annum as compared
with 197 cases and a rate
of 0.43 the preceding year (table 27). The NATOUSA Essential Technical
Medical Data for
March 1944 cited diphtheria reported in British (excluding Dominion or
colonial troops) and
American troops during a 3-month period as follows:
A high percentage of various types of
paralyses has been noted
in the course of diphtheria in the
British forces. The majority of these paralyses occurred in patients
whose diphtheria was
cutaneous rather than pharyngeal in location and varied from mild local
instances of neuritis to
rather extensive polyneuritis disturbances.
This was highly significant in that it clearly
pointed up the
problems of cutaneous diphtheria and
diphtheritic polyneuritis. Statistics are not available on the
incidence of cutaneous diphtheria in
United States Army troops in the North African and Mediterranean
theaters, although it is known
that it did exist, though obviously not to any marked extent.
Infectious polyneuritis, however,
was a problem of considerable interest and importance, and on 16
October 1944 the Surgeon,
NATOUSA, listed infectious polyneuritis as one of the major disease
problems of the theater and
directed a study of the situation.21
Diphtheria continued to be
somewhat of a
problem among troops
in Italy through the winter of 1945, although, with the reduction in
strength of United States troops
in that theater as the war came to an end, the actual number of
reported cases was not large. It
would appear that cases developed sporadically in all sections of the
theater and did not reach
epidemic proportions in any specific areas or units. Because of the
continuing presence of and
interest in polyneuritis, Major Schoenbach and Dr. George D. Gammon of
the Commission on
Neurotropic Virus Diseases were sent by The Surgeon General to Italy
during the summer of 1945 to
investigate the polyneuritis situation with particular respect to its
possible association with
diphtheria. It was found impossible to differentiate the various types
of polyneuritis by laboratory
means; however, the history of diphtheria preceding the onset of
polyneuritis in many cases and the
high carrier rates for virulent C. diphtheriae found in the areas
studied gave, presumptive evidence
that diphtheria was the etiologic agent in a substantial number of
21 See footnote 3. p. 167.
EXPERIENCE IN THEPACIFIC
Available information was scattered at the time of
Pearl Harbor and thereafter concerning diphtheria in the various
sections of the Pacific where United States forces were to be deployed.
From figures that could be obtained, there was at the time little
indication the disease would present a serious problem. The following
information on diphtheria in the various islands in the Pacific was
compiled by the Medical Intelligence Division, Office of the Surgeon
Diphtheria cases reported
regularly. The death rate from diphtheria was 1.4 per 100,000
population in 1940.
The vast majority of reported cases occureed
on the island of Oahu. In fiscal year 1942, 73 cases of diphtheria
were reported, 65 of which
occurred in Oahu, (43 in Honolulu and 22 in rural area), 2 occurred in
occured in Maui and Lanai, and 3
occurred in Kauai. That year, no deaths from diphtheria were
preceding years, the reported number of
diphtheria cases wre slightly larger, with a small number (2 of 6)
Gilbert and Ellice Islands,
Diphtheria occurred occasionally in the Gilbert
Islands but was not reported from Ocean Island or Nauru.
Ocean Island and Naura
Available sources did not state whether or not it occurred in the
diphtheria mentioned here, but no definite reports of cases found.
Diphtheria occasionally was reported from Dutch New Guinea. In 1937, an
epidemic occurred along the north
between Hollandia and Demta; 153 cases with 32 deaths were observed
between August and November.
sporadic cases were reported from British New Guinea. There was no
information with regard to
vaccination, and the danger of development of major epidemics was
Diphtheria had occurred sporadically among both the
European and native populations. It was felt thta the danger
development of major epidemics was ever present om this population
which had little natural immunity and no
information regarding prophylactic
Diphtheria was endemic and frequently epidemic in
most parts of the island. Between 1938 and 1944, several
Diphtheria was rare, but
a few cases had been reported. In 1930, 10 cases (2 fatal) were
reported from the
hospital in Guam.
endemic. There were large numbers of carriers.
Diphtheria had been reported but appeared to have been
mild in character.
Izu, Bodin, Kazan, and Marcus
Diphtheria was comon. There were 33
cases with 7 daths reported in 1936 of which 14 occurred in the Izu
Islands (Oshima 4; Niijima, 8 (2
deaths); Hachijojima, 2 (1 death); and 19 with 4 deaths in Ogasawara
British Solomon Island Protectorate
No diphtheria as reported from these island in
the 1930's and early forties.
Molukken Islands and islands in the
Diphtheria had been reported only from Ceram. There
the infection was formerly said to be rare but in recent
Eastern Part of the Banda Sea.
years had been recognized.
Diphtheria had not
disease is rare, cases of diphtheria had been reported from the islands.
A number of sporadic cases of
diphtheira hd been reported each year from the Philippines, but there
no recent large epidemics. In 1938,
there were 468 recorded cases with 157 deaths throughout the archipelago
Since 1925, there had been a progressive increase in the number of
cases listed each year, but the mortality
had remained more or less stationary. It was believed that the increase
in reported incidence might be due to
better reporting and to the establishment of more diagnostic
laboratories, rather than to an actual spread of the
Diphtheria was said
to be common here although only 38 deahts in Kagshima Prefecture and 17
Okinawa Prefecture were
reported drom this case in 1938.
Japan (exluding Okinawa)
of diphtheria was higher in Japan than in the United States, especially
in some of the northern
prefectures where the rates varied between 68 and 84 cases per 100,000
population in 1938. The disease
increased moderately for Japan as a whole between 1938 and 1940, there
being 28,420 cases with 3,853
deaths reported in 1938 and 38,412 cases with 4,288 deaths
reported in 1940. It was felt thta, with a
deterioration in health conditions, including excessive overcrowding,
diphtheria might become a disease of
potential military importance.
Though it was believed that diphtheria
occurred in a mild formn in many of the islands of the South Pacific, no
reliable evidence was available to show that
this disease was present in the Samoan Islands.
reference to diphtheria was found.
Lesser Sunda and Southwestern
Diphtheria was not rare; acute outbreaks
occasionally were observed. In 1935, an epidemic raged in Koepang.
All children were immunized and the
Contrary to expectations based on existing knowledge
as to the prevalence of diphtheria in the Pacific, the disease proved
somewhat troublesome, and cutaneous diphtheria was an unanticipated
complication.As seen in table 27, the over-all morbidity rates for the
years 1942-45 were 0.33 per 1,000 strength per annum for the Southwest
Pacific (615 cases reported), and 0.41 per 1,000 per annum for the
Pacific Ocean Area (519 cases reported). Undoubtedly, these represent
only a fraction of the total; in this theater, as well as in others,
many cases were not diagnosed unless complications developed.
United States Marines invaded Guadalcanal in August
1942, and that island finally was evacuated by the Japanese in February
1943. Early in 1943, the presence of diphtheria, both cutaneous and
pharyngeal, was recog nized among Army troops who had served in the
Solomon Islands.22 On 20 October 1943, Col. (later Brig.
Maxwell, Surgeon, United States Army Forces, South Pacific Area, issued
Medical Circular Letter No. 5 calling attention to the following:
Contrary to common belief infections with C. diphtheriae have not been rare
in this theater. As a certain number of these infections have been
overlooked, occasionally until the development of neuritis has provoked
further investigation, it is thought wise to direct attention to them.
same letter attention was called to cutaneous diphtheria in the form of
On 16 March 1944, Col. Benjamin M. Baker, Jr., MC,
theater consultant in medicine, sent a detailed report to General
Maxwell 23 which gave an account of studies
in Bougainville and Fiji on troops evacuated from the Solomon Islands
campaign. Approximately 25 cases were from the 164th Infantry Regiment,
and 100 cases from the 25th Infantry Division. A later report 24 stated
that of 291 cases of diphtheria in 1944 among troops who had served in
the Solomons, 155 (or approximately one-half) were of the cutaneous
type. In Colonel Baker's letter of 16 March it was stated further that
both bulbar and peripheral neuritis have followed the two types of
disease encountered. Approximately 2,800 men of the 164th Infantry
Regiment were Schick-tested and 38 percent had positive reactions. It
was of interest that 22 of 54 cases of cutaneous diphtheria, from whom
virulent C. diphtheriae had
been isolated, were in individuals who had been Schick positive at the
time of original examination.Many, but not all, of these subsequently
became Schick negative. All those who showed Schick-positive reactions
in the 164th Infantry Regiment and 25th Infantry Division received 0.5
cc. of alum precipitated toxoid followed by 1.0 cc. Approximately 50
percent of those injected developed local reactions of moderate
severity, and 10 percent developed incapacitating febrile reactions
necessitating hospitalization for several days."The measure
[immunization] coupled with ordinary isolation of cases controlled the
22 Stevens, F. W.: Medicine-South Pacific
Area. [Official record.]
23 Letter, Col. B. M. Baker, MC, to Brig. Gen.
Earl Maxwell, Headquarters, U. S. Army Forces, South Pacific Area, 16
24 Annual Report, Headquarters, South Pacific Base
Command, 1945, p. 8.
of diphtheria in the 164th Infantry Regiment miraculously."This,
incidentally, is one of the few reports of large-scale immunization of
combat troops in World War II.
The story of diphtheria in troops engaged in the
Solomon Islands campaign was repeated in Saipan and to a lesser degree
in Biak, Leyte, Hollandia, and other areas. An excellent, detailed
study of the problem of cutaneous diphtheria was made by Lt. Col.
Averill A. Liebow, MC, Maj. Paul D. MacLean, MC, Lt. Col. John H.
Bumstead, MC, and Maj. Louis G. Welt, MC, all of the 39th General
A survey of native populations of the Solomon
Islands, the New Hebrides, and the Marianas revealed widespread
existence of virulent C. diphtheriae,
chiefly in skin lesions. Most of the people in these islands over 3
years of age were Schick negative; obviously they had become immune as
a result of contact with the organisms through skin lesions rather than
through pharyngeal infections which appeared to be unusual.
EXPERIENCE IN INDIA-BURMA THEATER
No health statistics were available, for India and
Burma following 1939. However, the Medical Intelligence, Division,
Office of the Surgeon General, reported that, in 1939, Burmese
hospitals had treated 646 persons for diphtheria of whom 22 had died,
thus pointing at least to the existence of diphtheria at that time.
Information from India was scattered, and there was evidence merely to
indicate that the disease did occur among the native populations of
most provinces. Bensted 26 in 1936, reported
all outbreak of cutaneous and faucial diphtheria among British troops
in northwest India, and Hamburger 27 described cutaneous
northeast India in 1939.
Col. Herrman L. Blumgart, MC, and Maj. George M.
Pike, MC, recorded the high incidence of diarrheal diseases and malaria
in India-Burma. and the serious degree to which they contributed to the
noneffective rate in that theater.28 They added "scrub
cutaneous diphtheria, though less important statistically, hampered
military operations because of their occurrence in combat areas and the
serious disability which they occasioned." As shown in table 27,
there were 208 cases reported for the theater for the period January
1942 through December 1945, with an over-all rate of 0.47 per 1,000
strength per annum. Undoubtedly, this rate is below the actual
occurrence of the disease.
On 8 October 1944, Maj. Clarence S. Livingood, MC,
Chief, Section of Dermatology and Syphilology, 20th General Hospital in
Assam, reported 29
25 Liebow, A. A., MacLean, P. D., Bumstead, J.
H., and Welt, L. G.: Tropical Ulcers and Cutaneous Diphtheria. Arch.
Int. Med. 78: 255-295, September 1946.
26 See footnote 2, p. 167.
27 Hamburger, H. J.: Observations on the
Pathology and Therapy of the So-Called Frontier Sore. Indian M. Gaz.
151-155, March 1939.
28 Blumgart, H. L., and Pike, G. M.: History of
Internal Medicine in India-Burma Theater. [Official record.]
29 Letter, Maj. C. S. Livingood, MC, to
Commanding Officer, 20th General Hospital, India-Burma Theater, 9 Oct.
1944, subject: Cutaneous Diphtheria.
on the problem of cutaneous diphtheria which had begun at that hospital
the preceding June. Approximately 83 such cases had come under
observation. The great majority of these cases had acquired the disease
in combat in the Myitkyina area under circumstances of poor hygiene,
wet and soiled clothing, insect bites, abrasions, and the like. As of
December 1944, a total of 140 cases had been treated at the 20th
General Hospital, and a detailed report was issued by Major Livingood
in. January 1945 30 in which the following 20th General
officers collaborated: Lt. Col. (later Col.) James S. Forrester, MC,
Chief, Laboratory Section; Maj. Herbert S. Gaskill, MC, Chief,
Neuropsychiatry Section; and Maj. Calvin F. Kay, MC, Chief,
One of the problems associated with cutaneous
diphtheria proved to be the question of bacteriologic diagnosis. Among
a group of 119 clinically diagnosed cases at the 20th General Hospital,
virulent C. diphtheria were
isolated from 21 percent, diphtheroids from 46.8 percent, and other
organisms from 32.2 percent. As the experience of the laboratory
personnel increased the percentage of isolations improved, yet virulent
organisms never were recovered from many cases, especially those which
were first seen a number of weeks after the onset of the lesions.
Postdiphtheritic polyneuritis occurred in about 34
percent of the cases of cutaneous diphtheria, and myocarditis in about
While faucial diphtheria unquestionably was present
in the India.-Burma theater, it appeared to have offered no particular
Because of the importance of cutaneous diphtheria as
reported from both India-Burma and the Pacific, War Department
Technical Bulletin 143 was published and circularized by The Surgeon
General in February 1945.
EXPERIENCE IN OTHER AREAS
From January 1942 to December 1945, inclusive, a
total of 19 cases of diphtheria. were reported from the North American
area (including Alaska and Iceland), and 23 from Latin America., with
morbidity rates of 0.04 and 0.06 per 1,000 per annum, respectively
(table 27). Cases were scattered and the disease caused no particular
problem. Similarly, in the Persian Gulf Command only a few scattered
cases of diphtheria occurred and these also caused no particular
INCIDENCE AMONG PRISONERS OF WAR
During the summer of 1943, German prisoners captured
in the North African campaign began to be brought to the United States
for internment. Many of these prisoners apparently were carriers of
virulent C. diphtheriae;
30 Letter, Maj. C.
S. Livingood, MC, to Commanding Officer, 20th General Hospital,
India-Burma Theater, 25 Jan. 1945, subject: Cutaneous Diphtheria.
31 Annual Reports,
Headquarters, Persian Gulf Command, 1943; 1945 (1, 2d, and 3d
several outbreaks of diphtheria occurred, although in general, the
disease was well confined to the prisoner groups. One such outbreak
among prisoners interned at Aliceville, Ala., has been described in
detail by Capt. Stephen Fleck, MC, Capt. (later Maj.) John W. Kellam,
MC, and Maj. (later Lt. Col.) Arthur J. Klippen, MC.32
Fifty-one cases of diphtheria were diagnosed among a group of
approximately 5,000 prisoners over a period of about 2 months.
Diphtheria was a serious problem among German
prisoners confined in enclosures on continental Europe, particularly in
southern France. Col. John E. Gordon, MC, described the situation in
the European Theater of Operations as follows: 33
During the period of active operations more
than twice as many cases of diphtheria occurred among German prisoners
of war than among the much greater numbers of American troops. From
September 1944 to June 1945, inclusive, diphtheria cases among United
States troops numbered 1,202; and for prisoners of war the figure was
2,859. The rates were of course far greater, in the order of about ten
times * * * .
Only incomplete data are available for deaths. The
Advance Section of Communications Zone cared for 695,400 prisoners
during the six-week period from 1 May to 15 June. During that time,
1,080 cases of diphtheria occurred among the prisoners, of whom 40
died. The mortality rate per thousand per year was thus 0.499 and
the case fatality 3.7 percent. Prisoners of war included numbers of
relatively young persons, some aged no more than 14 to 16 years, and
the greater case fatality was therefore not altogether unexpected.
The carrier rates in some of the prisoner-of-war
enclosures were exceedingly high. In some groups sampled by Dr. Mueller
and the author during July 1945, as many as 10 percent harbored
virulent C. diphtheriae.
These high carrier rates prevailed chiefly in the enclosures in
southern France where prisoners had been confined since the winter and
early spring of 1944-45. Among groups of prisoners taken in the final
months of the invasion of Germany there was less diphtheria, and the
carrier rates were substantially lower, in the range of 1 to 2 percent.
TYPES OF VIRULENT C. DIPHTHERIAE
The British for some years have placed emphasis on
the relative virulence of the recognized types (gravis, mitis, and
intermedius) of C. diphtheriae.
Cruickshank 34 wrote in 1943 as
A knowledge of the infecting type should be
of some help to the clinician in his handling of a case of diphtheria.
The severity of the infection and the incidence of complications varies
with the type, the more severe toxaemic infections with a fairly high
incidence of paralysis (10-15%) being due to gravis and intermedius
types, while mitis is nearly always associated with a mild infection
except when it produces laryngeal diphtheria.
Brigadier R. E. Tunbridge, medical consultant to the
21st Army Group, British Land Army at Bad Oeynhausen in Germany, stated
that in a series of approximately 400 consecutive cases of diphtheria
in which careful typing of
32 Fleck, S.,
Kellam, J. W., and Klippen, A. J.: Diphtheria Among German Prisoners
of War. Bull. U. S. Army M. Dept. No. 74,80-89. March 1944.
32 See footnote 13, p. 171.
34 Cruickshank, R.: Diphtheria; Laboratory Aspects. Pub.
Health 57: 17-19, November 1943.
all strains was done, the complication rate following infection with
the gravis type was about 25 percent whereas the complication rate
following infection with the mitis type was about 12 to 14 percent.35
At the time, Brigadier Tunbridge stated that the British had
picked up a few cases of diphtheria due to the intermedius-type
organism, but a sufficient number of these cases was not available to
permit conclusions as to how the complication rate following
intermedius infection compared with the rates following infection with
the other two types.
The only area in which type studies were carried out
to any degree in United States troops was the European theater, and
then only after the cessation of hostilities.From surveys and other
information secured by Dr. Mueller and the author during the summer of
1945, approximately 80 percent of the strains on continental Europe
were of the mitis type and 20 percent of the gravis type. No
intermedius-type strains were picked up that summer. It was impossible
to obtain any information which would permit correlation with strain
type and severity of infection or rate of complications. Most, United
States Army medical officers, as well as a number of German physicians,
were of the opinion that there was no relationship between type of
organism and severity of infection.
There is practically no information concerning the
types of C. diphtheriae
encountered in the Pacific, although in a report on cutaneous
diphtheria in United States troops in the Pacific, by Lieutenant
Colonel Liebow and associates,36 the
statement was made that all organisms found were of the mitis type and
that no organisms of the gravis type had been encountered.
No information is available concerning types of
virulent C. diphtheriae
encountered among United States troops or
prisoners of war in the Zone of Interior.In this connection, it should
be pointed out that American authori ties have not shared the British
opinion as to the importance of strain type in respect to virulence and
likelihood of complications, and the only major attempt to type
organisms was made in the European theater after the cessation of
hostilities in the summer of 1945.
AR 40-210, 15 September 1942, provided that patients
known to be ill with diphtheria be hospitalized and isolated, that
contacts be inspected daily for 5 days, that contacts be excluded from
foodhandling until shown to be free from virulent C,. diphtheriae, and that known
carriers be isolated and given suitable treatment. Provision was made
for immunization against diphtheria "when in the opinion of the surgeon
this procedure is necessary for the prevention or control of diphtheria
in the command."These provisions were included
35 Tunbridge, R. E.: Personal communication to author
at Bad Oeynhausen, Germany, 30 July 1945.
36 See footnote 25, p. 181.
in essentially the. same form in AR 40-210 as revised and published on
25 April 1945. Obviously, the implementation of these regulations was
dependent upon recognition of the disease. Through lack of experience
with diphtheria in civilian training and practice, the United States
Army medical officer of World War II initially was weak in the
recognition of this disease.In those theaters where diphtheria was
encountered to any degree, Army physicians learned rapidly much about
the disease, and through their experience medical officers in other
theaters were alerted.
Laboratory officers, like clinicians, for the most
part had to gain their first major experience with C. diphtheriae. The position of the
laboratory was an important one in the detection and management of
carriers as well as in confirmation of the clinical disease. A
number of instances are on record where laboratory errors resulted in
misdiagnosis of pharyngitides, and in hospitalization and quarantine of
carriers of nonvirulent diphtheroids. Again, as war progressed
and laboratory officers had increased experience, correlation between
clinician and bacteriologist reached a high standard of efficiency.It
would seem appropriate to quote here a statement by Dr. Mueller: 37
* * * It may not be out
of place to
refer briefly to the purpose of the laboratory examination for the
diphtheria bacillus and to how much the clinician should expect from
it. The laboratory cannot "diagnose" diphtheria-that is the function of
the physician. The bacteriologist may be able to state, following a
delay of 12 to 15 hours, that organisms which he believes are
consistent in morphology with C.
diphtheriae are present in his culture. If he has had long
practical experience in the matter, he may be able to make a similarly
tentative statement even sooner, by examination of a direct smear made
from the throat swab, but such an opinion is best not ventured by the
inexperienced. Moreover, the failure to observe the organism in early,
or even later, culture by no means excludes diphtheria in the
patient.An improperly taken throat swab may yield entirely negative
results, although more careful subsequent culturing may show the
organism to be present abundantly in certain areas.
Under optimal conditions, the
report after from 2 to 4 days that a virulent diphtheria bacillus has
been obtained from the culture. This does not of itself establish a
clinical diagnosis of diphtheria, for the condition may have occurred
in the throat of an immune carrier and may have been entirely
nondiphtherial in nature.The decision as to the initial diagnosis and
treatment of the case is the direct and immediate responsibility of the
It must be recognized that even in the best
hands, and under ideal circumstances, the complete laboratory diagnosis
of diphtheria (including virulence testing) requires time, considerable
glassware and media, and an animal colony. Under conditions of combat
and rapid movement, it was impossible to provide all the refinements
necessary for good laboratory control of diphtheria, and such
facilities during a large part of the war were limited largely to the
army laboratories, and to a few of the more or less fixed general
37 Mueller, J. H., and Miller, P. A.: A
New Tellurite Plating Medium and Some Comments on the Laboratory
"Diagnosis" of Diphtheria. J. Bact. 51: 743-750, June 1946.
hospitals. It is obvious that a great need exists for relatively
simple laboratory procedures for the identification and virulence
testing of C. diphtheriae.
After the cessation of hostilities in Europe in May
1945, very active
measures were taken to improve the management and control of diphtheria
in the European theater. At the request of Maj. Gen. Paul R. Hawley,
Chief Surgeon, European Theater of Operations, The Surgeon General sent
Dr. Mueller and the author to the European theater on 16 June, and
during the next 2 months these consultants conferred with medical
officers at all levels of command in most of the major installations on
the Continent.Particular emphasis was placed on the establishment of
uniform bacteriologic techniques. Circular Letter No. 69, Headquarters,
Theater Service Forces, European Theater of Operations, 28 September
1945, outlined in great detail the techniques of the bacteriologic
diagnosis of diphtheria, and introduced the use of the new
tellurite-plating medium which had been developed by Dr. Mueller. This
plating medium offers a greatly improved method of screening large
numbers of throat cultures as compared with the traditional examination
for the diphtheria bacillus based on the microscopic appearance of a
stained smear from a culture on Lofer's medium. Furthermore, it makes
possible a gross differentiation of the several types (mitis, gravis,
and intermedius) of C. diphtheriae.
As stated before, AR 40-210, 15 September 1942 and
25 April 1945, provided for immunization against diphtheria "when in
the opinion of the surgeon this procedure is necessary for the
prevention or control of diphtheria within the command." Routine
immunization against diphtheria was not recommended for several
reasons. Although it was recognized that the age distribution of
diphtheria had been shifting in recent years and that the disease was
becoming more and more one of young adults, it was thought that a
sufficiently high proportion of United States troops possessed actual
or latent active immunity to diphtheria to prevent a significantly high
incidence of the disease, except under unusual conditions. An important
consideration in the decision not to immunize troops routinely was
based on the knowledge that injections of diphtheria toxoid would be
followed by moderate to severe reactions in an appreciable number of
Instructions on the subject of active immunization
against diphtheria in World War II were first issued in the Surgeon
General's Circular Letter No. 162 in 1942. These instructions
recommended plain or fluid toxoid in doses of 0.5, 1.0, and 1.0 cc.,
given subcutaneously at intervals of approximately 3 weeks. Reference
also was made to the reactions to be expected, and it was recommended
further that immunization be limited to Schick-positive individuals and
then only in the presence of a definite hazard from the disease.
Because of the unexpected occurrence of diphtheria in United States
troops in the Pacific, the presence of the disease among troops in
Africa and the threat of diphtheria on the continent of Europe, TB MED
(War Department Technical
Bulletin (Medical)) 47, published on 28 May 1944, contained a detailed
description of the disease and recommendations concerning immunization
similar to those contained in Circular Letter No. 162 (1942) as
described. On the basis of the studies previously mentioned which were
conducted at Camp Ellis and Camp Tyson by Colonel Long and
associates,"38 TB MED 114 was published on 9 November
1944 in which a
number of changes were made in the immunization recommendations. These
* * * When time and facilities permit,
preliminary Schick testing may be done and only the positive reactors
should be immunized. However, because of the time required, the
meticulous care necessary to obtain reliable results, and other
inherent difficulties, mass Schick testing will seldom be feasible and
the entire group requiring immunization should be given toxoid [plain]
in the measure described below.
Method of immunization. Reactions to
diphtheria toxoid are more common in adults than in children and,
therefore, it is desirable to begin with a dosage of 0.1 cc..
subcutaneously, and to limit further immunization to those who do not
react severely to this test dose. The occurrence, after any dose
in the series, of local edema or induration more than 6 cm. in
diameter, or a marked constitutional reaction with fever over 101o F., is a contraindication to further closes. The group given the
test dose should be inspected after 48 hours. Those who have not
experienced severe reactions may be given the first regular immunizing
dose of 0.5 cc. at this time. From this point subsequent doses
are given at 3-week intervals, the second and third immunizing doses
being 1.0 cc. Even though the entire series cannot be completed
for some individuals because of reactions, this procedure should raise
the general level of immunity sufficiently to prevent an epidemic of
In general, these recommendations concerning
technique of immunization were employed for the remainder of the war.
In the fall of 1945, because of the sharp increase
in diphtheria among the personnel of certain general hospitals in the
United States, Army Service Forces Circular No. 415, dated 9 November,
directed that all such persons coming into contact with patients be
Schick tested and those showing positive reactions be immunized. This
is the only instance during the war of the application in this country
of a diphtheria-immunization program instituted by War Department
directive. Up to the end of 1945, diphtheria immunization was carried
out only in a few instances in overseas installations. Some
immunizations were done in the North African-Mediterranean theater
because of the high incidence of diphtheria among civilians.In 1944,
Schick testing followed by immunization was carried out in the 64th
Infantry Regiment of the 25th Infantry Division in Bougainville and the
Fiji Islands. Although 10 percent of those injected (0.5 cc. followed
by 1.0 cc.) developed incapacitating febrile reactions, the measure was
considered to have, been instrumental in controlling the spread of
diphtheria in the regiment.39 Small immunization
programs also were conducted in the Persian Gulf Command, 40
and in the Alaskan Wing, Air
38 See footnote 11, p. 170.
39 See footnote 23, p. 180.
40 Monthly Sanitary Report, Persian Gulf Command, 8 Mar.
Transport Command.41 In
attention was drawn to the relatively high frequency of febrile
The great increase in diphtheria among troops
stationed in the European
theater in the summer and early fall of 1945 raised strongly the
question as to whether immunization should be made mandatory for
hospital personnel, at least. Because of the problem of
reactions, however, mandatory immunization was not adopted, and as a
compromise Circular Letter No. 69, Headquarters, Theater Service
Forces, European Theater of Operations, 28 September 1945, prescribed
that "where practicable, only immune personnel will be utilized in
caring for diphtheria patients."
Control of Carriers
In those theaters and regions where diphtheria was
prevalent, control of carriers was a difficult problem throughout the
war. Particular difficulty was encountered in the management of
individuals with chronic cutaneous diphtheria. It was frequently very
difficult to isolate organisms from these skin lesions, and yet
experience indicated that patients with chronic skin lesions were at
times serious sources of contagion.
The following statement was made in TB MED 47, 28
control. Before releasing carriers from isolation, negative
cultures should be required, as stated in paragraph 15 d (3), sec. IV,
AR, 40-210. If cultures have not become negative within 4 weeks,
consideration should be given to the removal of tonsils and adenoids
or[to]other appropriate treatment. Antitoxin is of no value in the
treatment of carriers.
Although statistics are not available, the
impression has been gained that many of the chronic carriers were
individuals with hypertrophied tonsils and that final clearance of
infection frequently was not accomplished until the tonsillar tissue
had been removed.
Fleming, in 1929, 42 demonstrated
that penicillin inhibited the growth in vitro of diphtheroid bacilli
and C. diphtheriae. On the
basis of this information, a study was conducted in the spring of 1945
among personnel and patients of the 3d General Hospital at
Aix-en-Provence, France. The results of this study, which was carried
out by Lt. Col. (later Col.) Samuel Karelitz, MC, Capt. Ralph E.
Moloshok, MC, and Capt. (later Maj.) Louis R. Wassermann, MC,43
indicated that large doses of parenterally administered penicillin
might be of value in clearing up the chronic carrier state. These
investigators also concluded that if penicillin was administered in
large doses, in addition to antitoxin, early during the acute disease,
fewer patients advanced to the chronic carrier state. They emphasized
emphatically that penicillin was not a substitute for antitoxin in the
treatment of the acute case.Colonel Karelitz
41 Monthly Sanitary Report, Alaskan Wing, Air
Transport Command, March
42 Fleming. A.: On. the Antibacterial Action of
Cultures of a
Penicillium, With Special Reference to Their Use in the Isolation of B.
Infuenzae.Brit. J. Exper. Path. 10: 226-236,
43 Karelitz, S., Moloshok, R. E., and Wassermann, L.
R.: Penicillin in
the Treatment of Diphtheria and the Diphtheria, Carrier State.ETO M.
Bull. 32: 67-72, July-August 1945.
and his group found that in their experience local application of
penicillin in the form of gargles was of no value in either the acute
disease or the carrier state. Capt. Harold W. Muecke, MC, conducted
studies of penicillin in the treatment of carriers at the 28th General
Hospital near Sissonne, France. 44 His
studies resulted in conclusions
essentially similar to those drawn by Colonel Karelitz and his
associates. Essentially, the same findings were obtained in a study
conducted under the direction of Col. Ross Paull, MC, at the Letterman
General Hospital, San Francisco, Calif., during the winter and spring
of 1945. 45
The situation with respect to carrier control as of
the end of 1945
might be summarized as follows:
1. Accurate determination of the carrier state was
dependent upon good
techniques in taking nasopharynbeal cultures supported by good
bacteriologic techniques in the laboratory, both prerequisites
frequently were lacking.
2. Many chronic carriers were individuals with
hypertrophied tonsillar and adenoid tissue, the removal of which often
was necessary to secure a cure.
3. Evidence was available which indicated that
parenteral penicillin in
large doses was effective in shortening the carrier state when
administered as well as late in the course of the disease.
4. Antitoxin again was found to be of no value in
the treatment of the
44 Muecke, H. W.: Personal communication
to author, 9 Aug. 1945.
45 Letter, Col. Ross Paull, MC, to Lt.
Col. A. P. Long, MC, 8 Sept.