Contents

Diseases Caused by Bacteria

CHAPTER X

Diphtheria

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 of considerable 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, which were 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 forces.

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 STATES

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

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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: 478-479, September 1919.

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 Polyneuritis in 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.

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TABLE 27.-Incidence 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 adults were 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.

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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. 1941.

⁶ Holt, L. Emmett, Jr., and McIntosh, Rustin: 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.

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TABLE 28.- Deaths due to diphtheria in the, U. S. Army, by area and year, 1942-45

On 10 November 1941, Lt. Comdr. (later Capt.) LeRoy 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 and Worcester and Cheever,¹⁰ was in part prompted by the epidemic of 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

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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, March 1948.
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.

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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 follows:

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. Each individual 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

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¹¹ Diphtheria Susceptibility and Immunization. Bull. U. S. Army M. Dept. No. 76, 104-108, May 1944.

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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 troops.

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 Letterman General 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 the dermatologic wards.Again, except for these special situations, diphtheria was not all important problem in the Zone of Interior.

EXPERIENCE IN EUROPEAN THEATER OF OPERATIONS

Great Britain.-From 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.

Western Europe.-In 1941, diphtheria began to increase in France,, Germany, The Netherlands, 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 alarming.This information, which was available early in 1944, served as a warning that diphtheria might be a disease

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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, North Carolina.

¹³

Gordon, J. E.: A History of Preventive Medicine in the European

Theater of Operations, L . S. Army, 1941-15. [Official record.]

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TABLE 29.-Diphtheria in England and Wales, 1939-45

of appreciable importance among infections to be encountered by troops invading France, the Low Countries, and Germany.

United States Army.-The rising tide of diphtheria in western Europe 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 confront our 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

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¹⁴ See footnote 13, p. 171.

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TABLE 30.- Incidence of diphtheria in civilian populations of Germany and Axis-occupied countries in Europe, 1939-43

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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 Epidemiological 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 months.It was 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 points

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¹⁵ Schulze, H. A.: Diphtheria in the U. S. Army in Europe.ETO M. Bull. 2 (No. 6): 2-26, June 1947.

¹⁶ Letter, Dr. J. H. Mueller and Lt. Col. A. C. McGuinness, MC, to The Surgeon General, 15 Aug. 1945, subject: Survey of Problems of Diphtheria. in ETO-Summary Report.

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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.

TABLE 31.-Diphtheria carriers in U, S. 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.

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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.

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TABLE 32.- Incidence of diphtheria in civilian populations in North African countries, 1942-45

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

United States 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 (table 27).

The Theater Surgeon, NATOUSA (North African Theater of Operations, United States Army), reported in 1943 that mumps, measles, diphtheria, Vincent's infections, German measles, 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 sharply increased 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 installations. The 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 Hospital during

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¹⁹(1) Istituto 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, 1946, p.58.(3) Ibid: nel 1942, 1947, p. 67.

²⁰Annual Report, Medical Section, Headquarters,

NATOUSA, 1943, p. 110.

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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 cases of diphtheria without 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 cases

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²¹ See footnote 3. p. 167.

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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 General:

Location

Remarks

Hawaiian Islands 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 Hawaii, 3 occured in Maui and Lanai, and 3 occurred in Kauai. That year, no deaths from diphtheria were reported. In preceding years, the reported number of diphtheria cases wre slightly larger, with a small number (2 of 6) deaths.

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 Ellice Islands.

Marshall Islands Occurrence of diphtheria mentioned here, but no definite reports of cases found.

New Guinea Diphtheria occasionally was reported from Dutch New Guinea. In 1937, an epidemic occurred along the north
coast between Hollandia and Demta; 153 cases with 32 deaths were observed between August and November.
Only sporadic cases were reported from British New Guinea. There was no information with regard to prophylactic vaccination, and the danger of development of major epidemics was considered serious

Bismark Archipelago Diphtheria had occurred sporadically among both the European and native populations. It was felt thta the danger of development of major epidemics was ever present om this population which had little natural immunity and no
information regarding prophylactic vaccination.

Borneo Diphtheria was endemic and frequently epidemic in most parts of the island. Between 1938 and 1944, several
severe epidemics occurred.

Caroline Islands Diphtheria was rare, but a few cases had been reported. In 1930, 10 cases (2 fatal) were reported from the
naval hospital in Guam.

Fiji Diphtheria was endemic. There were large numbers of carriers.

Formosa Diphtheria had been reported but appeared to have been mild in character.

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Location Remarks

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
Island Islands (Oshima 4; Niijima, 8 (2 deaths); Hachijojima, 2 (1 death); and 19 with 4 deaths in Ogasawara (Bodin
Islands)

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.

Pitcarine Island Diphtheria had not been reported.

Palau Islands Although the disease is rare, cases of diphtheria had been reported from the islands.

Philippine Islands A number of sporadic cases of diphtheira hd been reported each year from the Philippines, but there had been 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
disease.

Ryukyu Islands Diphtheria was said to be common here although only 38 deahts in Kagshima Prefecture and 17 deaths in Okinawa Prefecture were reported drom this case in 1938.

Japan (exluding Okinawa) The incidence 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.

Samoa 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.

Tonga Islands No 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.
Islands All children were immunized and the epidemic ceased.
Mariana Islands

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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. Gen.) Earl 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.

In this same letter attention was called to cutaneous diphtheria in the form of tropical ulcers.

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 spread
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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 Mar. 1944.
²⁴ Annual Report, Headquarters, South Pacific Base Command, 1945, p. 8.

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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 Hospital.²⁵

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 diphtheria in 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 typhus and 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
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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. 74: 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.

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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 Hospital 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, Cardiovascular Section.

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 3 percent.

While faucial diphtheria unquestionably was present in the India.-Burma theater, it appeared to have offered no particular problem.

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 difficulty.³¹

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;
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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 quarters).

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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 ENCOUNTERED

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 follows:

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
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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.

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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.

CONTROL MEASURES

Army Regulations

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
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³⁵ Tunbridge, R. E.: Personal communication to author at Bad Oeynhausen, Germany, 30 July 1945.
³⁶ See footnote 25, p. 181.

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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.

The Laboratory

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 laboratory can 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 physician.

It must be recognized that even in the best of 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
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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.

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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.

Immunization

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 cases.

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

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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 recommendations follow:

* * * 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 101^o 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 diphtheria.

In general, these recommendations concerning the 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
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³⁸ See footnote 11, p. 170.
³⁹ See footnote 23, p. 180.
⁴⁰ Monthly Sanitary Report, Persian Gulf Command, 8 Mar. 1944.

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Transport Command.⁴¹ In all instances, attention was drawn to the relatively high frequency of febrile reactions.

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 May 1944:

Carrier 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
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⁴¹ Monthly Sanitary Report, Alaskan Wing, Air Transport Command, March 1944.
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, June 1929.
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.

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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 chronically 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 carrier state.
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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. 1945.