Communicable Diseases, Table of Contents
CHAPTER VI
DIPHTHERIA
STATISTICAL CONSIDERATIONS
The influence of diphtheria on the admission rate of the Armywas not sufficient to place it among the 30 most important diseases, but itstood eighteenth among causes of death and twenty-eighth for time lost.
The interesting features of its occurrence are: It wasdecidedly more prevalent among white enlisted men than among colored; the casefatality rate was higher among the colored; there were only three instances ofthe prevalence assuming epidemic characteristics.
As shown in Table 33, the total annual strength of the Armyfor the period 1917-1919 was 4,128,479; the annual admission rate per 1,000 forthe period was 2.64; the death rate, 0.04 per 1,000; and the noneffective rate,0.21 per 1,000. Among native troops (Philippine Islands, Hawaii, and Porto Rico)the disease incidence was insignificant, 2 cases occurring in a strength of36,000 and no deaths. The annual admission rate among officers for the entireperiod was 1.56 per 1,000, as compared to 2.72 for enlisted men; the annualdeath rates, respectively, were: Officers 0.03 per 1,000 and enlisted men 0.04;the noneffective rates 0.10 per 1,000 and 0.22 per 1,000.
| Total mean annual strengths | Admissions | Deaths | Discharges for disability | Days lost | ||||
Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Ratios per 1,000 strength | Absolute numbers | Non- | ||
Total officers and enlisted men, including native troops | 4,128,479 | 10,909 | 2.64 | 177 | 0.04 | 80 | 0.02 | 317,050 | 0.21 |
Total officers and enlisted men, American troops | 4,092,457 | 10,907 | 2.67 | 177 | .04 | 80 | .02 | 317,023 | .21 |
Total officers | 206,382 | 322 | 1.56 | 7 | .03 | 1 | .00 | 7,835 | .10 |
Total American troops: |
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| White | 3,599,527 | 9,650 | 2.68 | 154 | .04 | 77 | .02 | 285,080 | .22 |
| Colored | 286,548 | 205 | .72 | 5 | .02 | 2 | .01 | 4,863 | .05 |
| Color not stated | --- | 730 | --- | 11 | --- | --- | --- | 19,245 | --- |
| Total | 3,866,075 | 10,585 | 2.72 | 170 | .04 | 79 | .02 | 309,188 | .22 |
Total native troops (enlisted) | 36,022 | 2 | .06 | --- | --- | --- | --- | 27 | .00 |
Total Army in the United States, including Alaska: |
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| Officers | 124,266 | 180 | 1.45 | 4 | .03 | --- | --- | 4,182 | .09 |
| White enlisted | 1,965,297 | 5,577 | 2.84 | 89 | .05 | 51 | .03 | 137,369 | .19 |
| Colored enlisted | 145,826 | 127 | .87 | 3 | .02 | 2 | .01 | 2,901 | .05 |
| Total enlisted | 2,111,123 | 5,704 | 2.70 | 92 | .04 | 53 | .03 | 140,270 | .18 |
| Total officers and men | 2,235,389 | 5,884 | 2.63 | 96 | .04 | 53 | .02 | 144,452 | .18 |
U.S. Army in Europe, excluding Russia: |
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| Officers | 73,728 | 137 | 1.86 | 3 | .04 | 1 | .01 | 3,563 | .13 |
| White enlisted | 1,469,656 | 3,921 | 2.67 | 61 | .04 | 22 | .01 | 143,552 | .27 |
| Colored enlisted | 122,412 | 74 | .60 | 1 | .01 | --- | --- | 1,923 | .04 |
| Color not stated | --- | 728 | --- | 11 | --- | --- | --- | 19,062 | --- |
| Total enlisted | 1,592,068 | 4,723 | 2.97 | 73 | .05 | 22 | .01 | 164,537 | .28 |
| Total officers and men | 1,665,796 | 4,860 | 2.92 | 76 | .05 | 23 | .01 | 168,100 | .28 |
Officers, other countries | 8,388 | 5 | .60 | --- | --- | --- | --- | 90 | .03 |
U.S. Army in Philippine Islands: |
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| White enlisted | 16,995 | 3 | .18 | --- | --- | --- | --- | 82 | .01 |
| Total enlisted | 21,451 | 3 | .14 | --- | --- | --- | --- | 82 | .01 |
U.S. Army in Hawaii, white enlisted | 16,161 | --- | --- | --- | --- | --- | --- | 47 | .01 |
U.S. Army in Panama, white enlisted | 19,688 | 19 | .97 | --- | --- | --- | --- | 206 | .03 |
U.S. Army in other countries not stated: |
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| White enlisted | --- | 26 | --- | 1 | --- | --- | --- | 919 | --- |
| Colored enlisted | --- | 1 | --- | 1 | --- | --- | --- | 6 | --- |
| Color not stated | --- | 2 | --- | --- | --- | --- | --- | 183 | --- |
| Total* | 14,232 | 29 | 2.04 | 2 | .14 | --- | --- | 1,108 | .21 |
Transports: |
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| White enlisted | 97,498 | 104 | 1.07 | 3 | .03 | 4 | .04 | 2,905 | .08 |
| Colored enlisted | 10,535 | 3 | .28 | --- | --- | --- | --- | 33 | .01 |
| Total | 108,033 | 107 | .99 | 3 | .03 | 4 | .04 | 2,938 | .07 |
Native troops enlisted: |
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| Philippine Scouts | 18,576 | 1 | .05 | --- | --- | --- | --- | 15 | .00 |
| Hawaiians | 5,615 | 1 | .18 | --- | --- | --- | --- | 12 | .01 |
aUnless otherwise stated, all figures for theWorld War period are derived from sick and wounded reports sent to the SurgeonGeneral.-Ed.
*Separate strength of white and colored not available.
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Table 34 shows the number of admissions and deaths, together with the annualrates, by months, of white and colored enlisted men, United States Army, forboth the United States and Europe.
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TABLE 34.-Diphtheria. Admissions anddeaths, by months, white and colored enlisted men, United States Army, UnitedStates and Europe, April 1, 1917, to December 31, 1919. Absolute numbers andannual ratios per 1,000 strength-Continued
The following summary from Table 34 shows the annual admission rates bylocation, years, and race:
For white troops in United States: |
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| 1917 | 3.42 | 1917 | 1.56 |
| 1918 | 2.62 | 1918 | .76 |
| 1919 | 2.78 | 1919 | 1.04 |
| For colored troops in American Expeditionary Forces: | ||
| 1917 | 1.60 | 1917 | 4.15 |
| 1918 | 2.90 | 1918 | .70 |
| 1919 | 2.30 | 1919 | .46 |
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A study of these figures shows that white troops had a muchhigher rate in the United States during 1917 and 1919 than did those in theAmerican Expeditionary Forces; while the latter, during 1918, the period ofgreatest activity overseas, had the higher rate. Seasonal variation was notsignificant, except that in 1917 the prevalence at home remained consistentlyhigh throughout the year; while in 1918 and 1919 it was high during late winterand spring, and low during the summer. In the American Expeditionary Forces theincidence rate was excessively high in July, 1917; it then dropped to a lowpoint and remained low until late winter, when it climbed rapidly, reaching thepeak in March and remaining fairly high until midsummer. During 1919 in theAmerican Expeditionary Forces the rise came in June and, except duringSeptember, remained high to the end of the year, reaching the high point of thewar (14.36 per 1,000) in December.
There seems very little correlation throughout the periodbetween the rate of prevalence at home and abroad. One might expect to find alag in the American Expeditionary Forces curve, showing a summer rise, producedby an influx of carriers from the spring peak in the United States; there issome indication of such a condition in the early part of 1918.
Considering the whole period, white troops in the UnitedStates had an annual admission rate of 2.84 per 1,000, while those in Europe had2.67. Among the colored troops the rate at home was 0.87 and in Europe 0.60.There is nothing significant in the difference shown between troops at home andabroad, and comparison is hardly justified. All troops numbered as in theAmerican Expeditionary Forces were also counted at some period among hometroops, and it is reasonable to presume that unknown passive carriers weresources both at home and in Europe.
Table 33 indicates that for the whole period, April 1, 1917,to December 31, 1919, the admission rate for the Army in the AmericanExpeditionary Forces was 2.92 per 1,000; while that of the Army at home was2.63. This difference of 29 cases per 100,000 men is not significant, and wasundoubtedly influenced, particularly in the early part of the period, byimported cases. For example, in December, 1917, the strength of colored troopswas 5,346 (Table 34), or 3 per cent of the entire strength, yet they furnished 3cases, or 15 per cent of the total (21) for that month. It is quite probablethat the cases in question originated in the United States.
OCCURRENCE IN THE UNITED STATES
Figures for the Army in the United States (Table 33) show atotal of 5,884b cases in anaggregate strength of 2,235,389, or an annual incidence rate of 2.63 per 1,000.The deaths totaled 96, making an annual rate of 0.04 per 1,000 and a casefatality rate of 1.6 per cent, or 16 deaths per 1,000 cases.
As noted previously and shown graphically in Chart XXX, therewas a noticeable difference between white and colored troops in resistance todiphtheria. As conditions of exposure were practically the same for both, thevariation in prevalence is best accounted for by the hypothesis of crediting thecolored soldiers with higher resistance or less susceptibility. However, whenthe appar-
bThis figure represents primary admissions.
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ent higher immunity in the latter race is broken down by invasion, there isless resistance to the toxic effect of the microorganism, and the case fatalityis much higher than among the whites; 23 per 1,000 as against 16 per 1,000.
The days lost for each case (Chart XXX) are practically thesame for white and colored, and the noneffective rate correlating with theadmission rate, is, of course, much higher for the white troops.
Officers in the United States (Table 33) show an aggregatestrength of 124,266 and 180 cases, or an annual rate of 1.45 per 1,000; amongthese there were 4 deaths, giving a case fatality of 2.22 per cent, or 22 deathsper 1,000 cases, which is considerably higher than that for the enlisted men (16per 1,000). It is interesting to note (Table 33) that the officer strength,124,266 is approximately within 20,000 of the colored strength, and the casefatality rates are fairly close, the difference being 1 death per 1,000 cases.
The lower incidence rate among officers is probably due totheir more advanced age, as we know that immunity to diphtheria increases witheach year beyond childhood. The higher fatality rate among cases may be assignedto the same hypothesis applied to colored troops. It is well known in allchildren's diseases attacking adults that the case fatality is high.Presumably, the adult victims are a small percentage who have built up little orno immunity, and the virus finds a favorable soil for development.
BY CAMPS
A study of Chart XXXI and Table 35 shows at once that camps inthe central area had a decided influence on the general admission rate. CampDoniphan, Okla.; Camp Pike, Ark.; Camp Funston, Kans.; Camp Grant, Ill.; andCamp Dodge, Iowa, furnished 17 per cent of the aggregate strength and 50 percent of the diphtheria.
These camps were populated from the agricultural area of theUnited States, and possibly a large proportion of the men had never beensubjected to the exposure incident to density of population and industrialconditions of the East, and hence had acquired less immunity. Chart XXXII showsgraphically the decided susceptibility of men from the agricultural States. Itis quite true that many of our southern camps drew men from agricultural regionsalso, but a large percentage of their strength was colored, which, as alreadyshown, had a decidedly racial resistance. The northwest area had a rate justbelow the average for the United States, but this position was characteristic ofthe men from this section, for all causes of admission.
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Among the camps in the Central United States which had high admission rates,the following case fatalities are found (calculated from cases and deaths, Table35):
Camp Pike, Ark.: | Camp Funston, Kans.: | ||
| Cases | 226 | Cases | 345 |
| Deaths | 8 | Deaths | 5 |
| Case fatality (per cent) | 3.54 | Case fatality (per cent) | 1.45 |
Camp Grant, Ill.: | Camp Doniphan, Okla.: | ||
| Cases | 216 | Cases | 577 |
| Deaths | 4 | Deaths | 7 |
| Case fatality (per cent) | 1.85 | Case fatality (per cent) | 1.21 |
Camp Dodge, Iowa: |
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| Cases | 173 | ||
| Deaths | 3 | ||
| Case fatality (per cent) | 1.73 | ||
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Chart XXXI indicates very clearly that Camp Doniphan, Okla.,led all stations in the United States as a diphtheria center. Keefer, Friedberg,and Aronson1 show that sporadic cases were present through the periodOctober, 1917, to February, 1918, when the admissions increased rapidly; therewas a slight fall during the first week of March and then a secondary rise,reaching the highest point during the week ending April 7.
The outbreak studied by these authors covered the periodOctober 7, 1917, to May 31, 1918, and included 461 of the 577 cases occurringbetween April 15, 1917, and December 31, 1919. The undue prevalence was rathersharply limited to February and March. A careful study was made of carriers and,as might be expected, the carrier rate paralleled the morbidity. As indicatedabove, the case fatality was low, pointing to low infectivity of themicroorganism. A study of occurrence by organizations showed decided resistanceon the part of those coming from urban centers, except among hospital personnel,where continued exposure to presumably heavy infection broke down the resistanceof urban as well as rural dweller.
In all other camps diphtheria was present, but did not showany alarming increase other than an occasional slight rise in admission rates,with seasonal changes, and the addition of carriers coming with augmentedpopulation.
OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES
Table 33 shows a total mean annual strength of 1,665,796 inthe American Expeditionary Forces, with 4,860 admissions, or an annual rate of2.92. There were 76 deaths, giving a case fatality of 1.56 per cent, or 15deaths per 1,000 cases. While the annual admission rate (2.92 per 1,000) ishigher than that for troops in the United States (2.63), the period of higherincidence is practically limited to the spring of 1918 and the fall of 1919. Thelatter period was one of markedly reduced strength, with concentration of troopsin the occupied area in Germany, and increased contact with civilian carriers inyounger age groups. The rate of incidence was not significant; for example, inDecember, 1919, there were only 22 cases. Since the strength now had fallen to18,379, the resultant annual rate for the month (14.36 per 1,000) is high.
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Considering diphtheria as a divisional problem, which itproperly became in the American Expeditionary Forces, there were only 2divisions of the total 42 in which the disease became at all alarming. Thehistory of diphtheria in each unit was traced by Neal and Sutton.2Both these divisions came from camps in the United States where there wasundue prevalence, namely, Camp MacArthur, Tex., and Camp Doniphan, Okla. It isquite reasonable to presume, then, that each division brought its own sources ofinfection in carriers, and the necessary crowding in trains, transports, andbilleting provided increased means of spread.
The two divisions affected were the 32d, which came from CampMacArthur, Tex., and the 35th, from Camp Doniphan, Okla.
The 32d Division had a constant source of known infectionfrom the time it left camp until it reached its area in France; that is, casesdeveloped in Camp MacArthur just before departure of the division (February 4,1918); others appeared en route to Camp Merritt, and while in this camp awaitingembarkation. Various units of the division were separated for transportation toEurope. It was well along in April, 1918, before the division was concentratedin its area in France, but the incidence of diphtheria in certain units as theyarrived was sufficiently high to demand immediate investigation. Surveysrevealed a considerable number of carriers as well as clinical cases. Severalunits of this division had practically no cases, while among others it reachedepidemic proportions.
The division moved into the Alsace sector on May 14, andcontinued having sporadic cases until about July 18, when the epidemic virtuallysubsided. The effect of this division's diphtheria is shown in the admissionrate for the American Expeditionary Forces during the spring of 1918. (See Table34.)
The 35th Division had a similar experience to that of the32d, but less alarming. There were, however, a sufficient number of scatteredcases constantly present to demand attention from June to September, 1918. Thedivision left Camp Doniphan about the time the epidemic, previously mentioned,was subsiding. Its subsequent diphtheria indicates, as might be expected, thatcarriers were present throughout the organization. The disease was quiteprevalent during the ocean voyage, and while in England 27 scattered cases werereported for the week ending May 29. The division moved shortly after this date,and on June 5 entrained in France for the American area. Forty-eight hours ofclose contact followed, and a week later there was a sharp rise in diphtheriaadmissions. The division finally reached its sector in the Vosges Mountains, andtroops were distributed in billets and dugouts. There was less opportunity inthis situation for contact and spread, and the morbidity rate declined.
During this same period a field laboratory was assigned tothe division, and all contacts were cultured and the Schick test was made onthem. The resultant weeding out of carriers, active and passive, was undoubtedlythe deciding factor in preventing an epidemic in the organization.
The concentration of American forces for the St. Mihiel andthe Meuse-Argonne operations found diphtheria well controlled and no longer acause for alarm, but now the hospital centers were beginning to feel itspresence.2
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IN HOSPITAL CENTERS
The first hospital center to report an undue prevalence wasthat at Mesves. One of its units, Base Hospital No. 54, found during the monthof October, 1918, that 1 per cent of its admissions was due to diphtheria, andseveral cases appeared among the hospital personnel. During the first two weeksof November, 1918, 34 cases appeared in the center personnel and 50 per centwere among those on duty at Base Hospital No. 54. The diphtheria prevalenceoccurred during the last three months of the year, when hospitals were badlyovercrowded, the center under discussion averaging 18,000 patients.
In the other centers, the disease was much less prevalentthan at Mesves, though quite a number of cases occurred among patients andpersonnel. Base Hospitals Nos. 25, 26, and 49, Allerey center, reported a numberof nurses and orderlies as carriers who had been diagnosed carriers in theUnited States.
PATHOLOGY
In the vast majority of instances during the World War thecharacteristic lesion, the false membrane, was located on the fauces. Itsextension into the larynx, trachea, and bronchi occurred, although notfrequently.
Other changes occurred due to the absorption of diphtheriatoxin or mixed infection. An analysis of 20 protocols on file in the ArmyMedical Museum, Washington, D. C., obtained from diphtheria cases autopsiedduring the World War, show the following pathological processes: Pleurisy, 5;laryngeal diphtheria or ulceration, 14; tracheal diphtheria, 9; extension intothe bronchi, 5; pneumonia, 15; endocarditis, 2; myocarditis, 9; pericarditis, 5;nephritis, 6; hydrothorax, 1; fatty degeneration of the heart muscle, 3; basilaredema, 1; meningitis, 1; gangrene of the tonsils, 1; edema of the glottis, 2;acute splenitis, 7; pneumothorax, 1; bullous emphysema, 2; cloudy swelling ofthe liver, 8, of the kidney 7, and of the heart, 5; petechial hemorrhage, 4;evidences of gassing, 3; septicemia, 6; urticaria, 1. The blood was examined fordiphtheria bacilli four times, all of which were negative. Duration of thedisease after admission to hospital varied from 1 to 19 days, with an average of5.3 days. The cases of longer duration, generally speaking, showed heartinvolvement.
Among 4,500 autopsy reports after pneumonia, the diphtheriabacillus was recovered in five instances, once from the bronchus and four timesfrom the consolidated lung. Among 13,246 autopsies in the American ExpeditionaryForces, 26 were on bodies of diphtheritic cases. A study of these protocolsshowed that 12 cases died during the acute stage of the disease. Of the others,11 died from later complications or contributory causes.
SYMPTOMS
Types of the disease by location of the membrane are: Faucial,nasal, laryngeal, bronchial, and wound diphtheria. The records of the WarDepartment do not permit of analysis for the total Army by such types; however,the vast majority of the cases were faucial; for example, at Camp Custer, Mich.,3among 55 cases the membrane was situated as follows: Pharynx, 4;
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tonsils, 41; tonsils and pharynx, 10; pharynx and larynx, 1;nose, 1. That cases of laryngeal diphtheria, and extension of the process intothe trachea, bronchi, and even into the lung tissue itself, occurred is shown byreports of tracheotomy and autopsy protocols; however, the exact number of suchcases in the Army is not known. In the severely gassed, pseudo membranes oftenoccurred in the bronchi and trachea which masked the diagnosis of diphtheria.
Depending upon the severity of the disease, diphtheria isarbitrarily divided into the following types: Mild, moderately severe, severe,and malignant. This classification was used by the Army during the World War asa basis upon which to determine the antitoxin dosage. Figures, by types, are notavailable, but numerous reports, at home and abroad, indicate that the diseasein epidemic form was relatively mild, and that though the more severe typesoccurred, they were in the minority.
COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES
Complications and sequel? constitute important phases in theclinical course of diphtheria. Among the total 10,909 primary admissions, 2,439complications were reported, with 107 deaths. The total number of deathscredited to diphtheria among primary admissions is 177. No explanation, otherthan diphtheria, is found for the cause of death among the remaining 70 cases.The case mortality for the total Army was 1.62 per cent.
The most important early complication was pneumonia. Thiscomplication is a frequent cause of death, more especially in the laryngeal formof diphtheria. Usually, it is due to a secondary infection by the pneumococcusor pus organisms. In 162 cases pneumonia was reported as a complication ofdiphtheria, as follows: Bronchopneumonia, 61; lobar pneumonia, 101. The deathrate, however, was far greater among the former. There were 10 deaths, or 9.9per cent, among the lobar cases and 27, or 44.2 per cent, among thebronchopneumonia cases.
Perhaps the next most important complications were thoseinvolving the heart. Of 21 clinical histories of diphtheria on file in theSurgeon General's Office, the cause of death in 4 cases was attributed topericarditis, in 2, to myocarditis, and in 1 to heart block. The average time inhospital before death was 7 days for cases with pericarditis, 6 days for thosewith myocarditis, and 6 days for those with heart block.
Neal and Sutton,2 studyingdiphtheria in the American Expeditionary Forces, attributed the myocarditis,cardiac paralysis, post-diphtheritic optic paralysis, laryngeal paralysis, andother nerve affections, as well as prolonged convalescence, to inadequatemethods of treatment. The clinical histories of 21 men discharged from theservice on account of disability following diphtheria show disability to havebeen due to mitral disease in 2 cases and myocarditis in 1. Tachycardia wasnoted in 25 of the primary admissions and neurocirculatory asthenia among 14.Among cases in which diphtheria was a concurrent disease, pericarditis was notedin 1, aortic insufficiency in 2, mitral insufficiency in 7, mitral stenosis in3, myocarditis in 7, tachycardia in 2, and neurocirculatory asthenia in 6.
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Among 47 protocols of fatal cases of diphtheria in the Armyduring the World War, laryngeal paralysis was a cause of death in 5. Of 21 casesdischarged from the service on account of disability following diphtheria, therewere 11 instances with paralysis of the upper extremity and 12 of the lower.Optic neuritis was a cause of discharge for disability in 9 cases. The caseswith paralysis of the extremities also had laryngeal paralysis in 3 instances.One case was discharged from the service on account of facial paralysis and oneeach for the following conditions: Otitis interna, myocarditis, psychasthenia,and paralysis of deglutition. Among the 2,439 complications of the cases ofdiphtheria in the Army, paraplegia was present in 3, and other paralyses in 14cases. Neuritis (without location) was present in 14 instances. No cases ofhemiplegia were reported.
Nephritis was an uncommon complication. It was reported in 20cases, 8 of which were acute and 12 chronic nephritis; that is, 0.81 per cent ofthe total complications. Among the nephritides there were 4 deaths, 3 of whichfollowed the acute form.
Meningitis is a rare complication. During the war, five casesof meningitis were reported among primary admissions for diphtheria, 2 of whichwere of the epidemic type. The Klebs-Loeffler bacillus was not recovered fromthe cerebrospinal system in any of these cases.
Occurrence of diphtheria with the exanthemata is well knownand at times offers difficult differentiation, particularly in some cases ofscarlet fever. Occurrence with the most important exanthematous diseases duringthe war was as follows:
Disease | Primary admissions |
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Measles | 98,225 | 23 | 0 |
Scarlet fever | 11,675 | 64 | 1 |
Chicken pox | 1,757 | 5 | 0 |
German measles | 17,378 | 4 | 1 |
Mumps | 230,356 | 90 | 1 |
| 359,391 | 186 | 3 |
DIAGNOSIS
The diagnosis of a typical faucial case is not difficult. Thepresence of a membrane in the throat of a patient acutely sick shouldimmediately suggest diphtheria, and the case should be observed and dealt withaccordingly until this tentative diagnosis has been confirmed by clinical andlaboratory means. The onset of diphtheria is acute; locally there is usually amembrane, and the patient is suffering from an acute toxemia. However, otherorganisms are capable of producing false membranes-pneumococcus,streptococcus, bacillus of Friedlander, and Bacillus pyocyaneus. Rarelyin diphtheria no membrane is formed. In practice the diagnosis of diphtheria isjustifiable, provided the patient is acutely sick, suffering from a membranoussore throat, the microscopical examination of which reveals the presence of anorganism morpho-
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logically similar to the Klebs-Loeffler bacillus. If thepatient has no constitutional symptoms, although diphtheria bacilli are found inthe exudates, he is a carrier of a virulent or an avirulent strain, andclinically the case is not one of diphtheria. Theoretically, in order toestablish a diagnosis of diphtheria, the patient must have local and generalsigns of the disease, the diphtheria bacillus must have been isolated from thelocal lesion in pure culture, it must have been proved to be virulent, and thecase must have responded to antitoxin. In practice, virulence tests are reservedfor carriers, and antitoxin is used for therapeutic or prophylactic and not fordiagnostic purposes on man.
Although the diphtheria bacillus is abundantly present in thelocal lesion, carelessly taken smears may fail to reveal them; therefore,cultures should be taken with care and from the most suspicious area. Dependencecan not be placed upon one negative culture.
Early diagnosis is of the greatest importance, not only fortreatment, but in prevention as well. Too much emphasis can not be placed onthis, since it was noted during the war, especially in the AmericanExpeditionary Forces, that battalion and regimental surgeons occasionally werereluctant to make a clinical diagnosis of diphtheria;2furthermore, some cases occurred on transports returning to the UnitedStates where late diagnosis was made and the cases terminated fatally on the dayof, or the day after, debarkation in the United States.
Differential diagnosis between diphtheria and folliculartonsillitis, Vincent's angina, scarlet fever, streptococcic sore throat,peritonsillar abscess, and syphilitic ulceration of the mouth is important. Inaddition to these, cases of retropharyngeal abscess, phlegmon of the glottis,and severe gassing must be carefully examined in order to differentiate fromlaryngeal diphtheria. Diagnosis based upon careful physical examination andbacteriological examination is possible. In the above-mentioned conditionsclinical examination alone may not furnish sufficient data for differentialpurposes. The fact must also be borne in mind that diphtheria may be engraftedupon one or the other of these conditions, or the case may be in reality adiphtheria carrier and clinically suffering from some other condition.Therefore, a correct diagnosis can be made only by a careful analysis of thephysical findings in conjunction with the laboratory report.
During the war, severely gassed cases in whom laryngealfibrino-purulent membranes were formed strongly resembled diphtheria. Medicalofficers serving overseas often remarked on the difficulty in differentialdiagnosis from diphtheria. The membrane in gassed cases, according to Barron andBigelow,4 covered the lining of the larynx andtrachea and extended from the epiglottis down into the bronchi and bronchioles.The tissues of the ventricles and vocal cords were at times markedly edematous,producing voice changes and mechanical obstructive breathing. This membranerarely extended up into the larynx or over the tonsils; but nearly all of theserious cases of diphtheria had severe laryngeal manifestations, so that even atautopsy it necessitated close scrutiny to differentiate between laryngealdiphtheria and laryngitis and tracheitis following gassing. Besides, diphtheriawas occasionally superimposed upon laryngitis following gassing.
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CONTROL AND PREVENTIVE MEASURES
The most important measures for control and prevention ofdiphtheria are early recognition of cases and carriers and their properisolation. Frequent inspections of men with sore throat, and culturing them willdetect the cases. Not infrequently, cases occur where the symptoms are mild andthe throat presents a beefy red appearance with but little membrane. Uponcareful examination, pinhead-sized patches may be seen. Such cases usually havean elevated temperature, and are important in the spread of the disease. Thewholesale culturing and administration of antitoxin to all those in mediate orimmediate contact is a thing of the past in dealing with masses of soldiers. Thecontrol of diphtheria is principally the detection and control of diptheriacarriers. Nichols5 makes the statement that intheory the detection and management of carriers have been carried almost toperfection, but in practice the system breaks down because the number of menexposed and the number susceptible are large. Since laboratory and clinicalfacilities are usually limited, only a certain number of cultures can beexamined daily, and a much smaller number of virulence tests made. Furthermore,a limited number of Schick tests can be made daily and several days ofobservation are needed, while only a few persons can be quarantined and heldunder observation. The result is, the bacteriological plan of attack fails andcommon sense must govern. Clinical cases are to be considered first, and as muchcarrier work done as is feasible.5
The Surgeon General, on January 1, 1918, outlined theprocedure to be followed in the case of diphtheria.6These instructions were briefly as follows: Strict isolation was to beinstituted. Male attendants were to be segregated and not allowed to eat orsleep with other members of the medical detachment. Nurses were to be providedwith special quarters and messing facilities. When on duty in the wards, allfemale nurses, male attendants, and medical officers were to wear operatinggowns, caps, and gauze masks over the nose and mouth; the hands were to bethoroughly washed and disinfected after coming off duty and before leaving theward. Cultures were to be taken every fourth day from the personnel on duty indiphtheria wards, and no nurse, officer, or enlisted man was to be assigned toother duty until negative cultures were obtained. The bedding, clothing, etc.,of patients and the gowns and caps of attendants were to be thoroughlydisinfected by steam or chemicals before going to the laundry; nasal and oraldischarges of patients were to be disinfected or burned; dishes, etc., were tobe sterilized before being returned to the general kitchen. Diphtheriaconvalescents and carriers were not to be returned to duty until threeconsecutive negative cultures, taken at intervals of from three to six days,were obtained. Diphtheria carriers were not to be segregated in the same roomwith men sick with diphtheria, but in a suitable segregation ward, camp, orbarrack. In addition the Schick test was to be applied to nurses and maleattendants, and those not immune were to be immunized.
Diphtheria patients were invariably hospitalized; also someof the carriers. When in hospital, they were assigned to special wards wherecubicles and masks were used. Weaver7 claimedthat, coincident with the use of the mask, there was an absence of diphtheriaand diphtheria carriers among the physicians and nurses of his hospital and onlya limited amount of throat infection. At Camp
249
Sherman, Ohio, before the days of universal masking, it wasdifficult to obtain a sufficient number of negative cultures of both diphtheriaand meningitis patients to permit their release from hospital.8At Camp Grant, Ill., experiments were conducted with the mask incontagious wards, and it was concluded that this was a valuable agent inpreventing cross infection.9 Hallerand Colwell10 conducted extensive experimentswith varying layers of gauze possessing different-sized fibers and mesh, andshowed that about six layers of ordinary gauze should be used. Barron andBigelow,4 stated that it wasimpracticable, of course, to mask all of the 16,000 individuals in the hospitalcenter where they worked, though one hospital of the center tried masking itsentire personnel. Cubicles were recommended by them to supplement the masks ofthe patients, since few could sleep with the mask in place. The original maskhad two layers of gauze with a mesh of 14 to 16. It was recommended by them thattwo such masks be worn, since two thicknesses were insufficient. The personalcooperation of the patients was held to be absolutely essential to individualquarantine.
The following thorough procedure was adopted at Camp Sherman, Ohio, in thecontrol and prevention of diphtheria there:8
(a) Procedures adopted in line organizations afterdiagnosis of a case:
Detection of one or two carriers does not call for quarantine.
All contacts of the company are segregated (intimate contacts).
All contacts are Schicked, cultured (nose and throat), and masked.
Transfer all carriers to hospital for observation and treatment and immunize all those showing positive Schick tests.
(b) Procedure in wards where diphtheria appears:
Where the patient is able to be transferred-
Transfer the patient to the diphtheria ward and do not institute quarantine.
Examine all close contacts by culture and Schick testing.
Mask all personnel and patients of the ward.
No patients will be transferred to other wards until the culture is negative.
If a case develops among the carriers, then reculture the entire ward.
Give prophylactic serum to all with positive skin tests.If the patient is too ill to be transferred-
Quarantine the entire ward and place the patient in a single room of the ward.
Culture and Schick test the entire ward and mask all patients and personnel.
Transfer all detected carriers to the carrier ward, if possible; if not, place them in cubicles.
Repeat the culturing at two-day intervals.
When the patient's condition permits, transfer him to the diphtheria ward.
Quarantine is lifted when two negative cultures are received.Procedure among suspects sent to hospital-
Mask them on entering the ambulance and hold under observation in an observation ward until a diagnosis is made and then make the transfer.
(c) Procedure in diphtheria and diphtheria-carrier wards:
At all times quarantined, cubicle the patients and mask the personnel.
Keep patients, convalescents, contacts, and carriers segregated by groups.
Several hospitals found it advisable to culture patients on admission,notably the hospitals at the port of embarkation, Hoboken, N. J.11
Although toxin-antitoxin mixtures were thought of during the war as aprophylactic measure, this means of conferring immunity was used to a verylimited extent. It was not considered a practical war measure on account of thetime required for administration and to establish immunity.
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TREATMENT
Laryngeal diphtheria, cases seen late for the first time intreatment, and those occurring as a complication of an exanthem, should beregarded as severe and treated accordingly. In severe cases, suspected of beingdiphtheritic, it is better to give antitoxin and not await the results oflaboratory reports, as valuable time may be lost. Cases of death due toanaphylactic shock are so rare that possible death from this cause does notjustify withholding antitoxin, even intravenously, where the severity of thedisease warrants its administration. However, in cases known to be sensitive tohorse serum, desensitization may be attempted. The favorite dose of antitoxinused in the Army was 20,000 units, injected, as one dose, into the buttock.There is no record of desensitization having been used before giving serumduring the war. If hypersensitiveness to serum is feared, an hypodermic ofadrenalin should be available for immediate injection. This precaution was takenby many medical officers.
A study of many World War protocols shows that antitoxin wasoften repeated; for example, in one case, in which death occurred 2 days afteradmission to hospital, 4 injections of 20,000 units each were given, 2subcutaneously and 2 intravenously. In another, where tracheotomy was performedimmediately on admission to hospital, 30,000 units were given intravenously. Asstated above, several cases were transferred from transports, upon arrival inthe United States, and died soon after debarkation from laryngeal diphtheria. Insome of these cases 50,000 units or more were given.
Tracheotomy was not an uncommon form of treatment inlaryngeal diphtheria in the Army. The low operation was the one of preference.However, so far as the available data show, all cases died; these cases wereseen late and irreparable damage was done before treatment was commenced.
The O'Dwyer intubation sets were freely distributed duringthe war, but there is no record of intubation having been performed.
As regards the treatment of serum sickness in diphtheria,this differs in no way from that occurring in any other disease. It usuallyappears a week or 10 days after serum administration and responds immediately tohypodermic use of adrenalin. Since this response is of short duration, however,the intense itching is relieved only temporarily; therefore a saline purgativeshould be given, which usually reduces the intensity of symptoms. This conditionis of short duration and commonly borne by soldiers without treatment. There isno discoverable record of sudden death occurring in the Army during the warfollowing the use of serum in any form.
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| Total mean annual strengths |
| Discharges for disability | Days lost | |||
| Ratios per 1,000 strength | Absolute numbers | Ratios per 1,000 strength | Absolute numbers | noneffective ratios | ||
Total officers and enlisted men, including native troops | 4,128,479 | 5,043 | 1.22 | 9 | 0 | 98,579 | 0.07 |
Total officers and enlisted men, American troops | 4,092,457 | 5,041 | 1.23 | 9 | 0 | 98,383 | .07 |
Total officers | 206,382 | 112 | .54 | --- | --- | 1,163 | .02 |
Total American troops: |
|
|
|
|
|
|
|
| White | 3,599,527 | 4,634 | 1.29 | 8 | 0 | 91,147 | .07 |
| Colored | 286,548 | 99 | .35 | --- | --- | 2,127 | .02 |
| Color not stated | --- | 196 | --- | 1 | --- | 4,126 | --- |
| Total | 3,886,075 | 4,929 | 1.27 | 9 | 0 | 97,400 | .07 |
Total native troops (enlisted) | 36,022 | 2 | .06 | --- | --- | 16 | .00 |
Total Army in the United States (including Alaska): |
|
|
|
|
|
|
|
| Officers | 124,266 | 80 | .64 | --- | --- | 665 | .01 |
| White enlisted | 1,965,297 | 2,957 | 1.50 | 8 | 0 | 49,235 | .07 |
| Colored enlisted | 145,826 | 76 | .52 | --- | --- | 1,264 | .02 |
| Total enlisted | 2,111,123 | 3,033 | 1.44 | 8 | 0 | 50,499 | .07 |
| Total officers and men | 2,235,389 | 3,113 | 1.39 | 8 | 0 | 51,164 | .06 |
U.S. Army in Europe, excluding Russia: |
|
|
|
|
|
|
|
| Officers | 73,728 | 32 | .43 | --- | --- | 498 | .02 |
White enlisted | 1,469,656 | 1,661 | 1.13 | --- | --- | 41,624 | .08 |
| Colored enlisted | 122,412 | 22 | .18 | --- | --- | 848 | .02 |
| Color not stated | --- | 195 | --- | 1 | --- | 4,116 | --- |
| Total enlisted | 1,592,068 | 1,878 | 1.18 | 1 | 0 | 46,588 | .08 |
| Total officers and men | 1,665,796 | 1,910 | 1.15 | 1 | 0 | 47,086 | .08 |
U.S. Army in Philippines Islands: |
|
|
|
|
|
|
|
| White enlisted | 16,995 | 1 | .06 | --- | --- | 8 | .00 |
| Colored enlisted | 4,456 | --- | --- | --- | --- | 14 | .01 |
| Total enlisted | 21,451 | 1 | .05 | --- | --- | 22 | .00 |
U.S. Army in other countries: |
|
|
|
|
|
|
|
| White enlisteda | --- | 10 | --- | --- | --- | 170 | --- |
| Color not stated | --- | 1 | --- | --- | --- | 10 | --- |
| Total | 14,232 | 11 | .77 | --- | --- | 180 | .03 |
Transports: |
|
|
|
|
|
|
|
| White enlisted | 97,498 | 5 | .05 | --- | --- | 110 | .00 |
| Colored enlisted | 10,535 | 1 | .09 | --- | --- | 1 | .00 |
| Total | 108,033 | 6 | .06 | --- | --- | 111 | .00 |
Native troops enlisted: Philippine Scouts | 18,576 | 2 | .11 | --- | --- | 16 | .00 |
aSeparate strength of white and colored notavailable.
252
CARRIERS
Only carriers who were admitted to hospital were reported tothe War Department; therefore no record was made of those kept in quarantineareas except when under hospital jurisdiction. This being so, it is impossibleto estimate the number of carriers detected in the Army during the World War,since various camps used their own methods of control. Table 36 shows the numberof primary admissions to hospital for diphtheria carriers. There were 5,043 suchadmissions for the total Army, the total mean annual strength being 4,128,479men. The ratio per 1,000 per annum was 1.22. Officers contributed 112 primaryadmissions, a ratio of 0.54, and enlisted men the remaining 4,929, which gave anannual admission ratio per 1,000 strength of 1.27 for the latter. The carrierstate was not common among colored troops; only 99 primary admissions werereported for colored troops against 4,634 for white troops. The ratios per 1,000were 0.35 and 1.29, respectively. The number of carriers among native enlistedtroops was negligible, there being but two reported.
In the United States there were 3,113 primary admissions forthe Army, with a ratio of 1.39 per 1,000 per annum; in the AmericanExpeditionary Forces there were 1,910, with a ratio of 1.15. Despite thesefigures, it is not believed that there were more carriers among the troops inthe United States than in Europe. Culturing was as extensively carried outabroad as in the United States, but the difference essentially is, more carrierswere admitted to hospital at home than abroad. This was primarily due to thefact that relatively more bed space was available in the hospitals in the UnitedStates than in the American Expeditionary Forces. Carriers, not being sick,could be cared for as well in isolation camps as in hospital. This method wasused extensively abroad. Carriers undoubtedly existed on transports, but it wasneither practicable nor advisable to undertake any extended search for theirdetection. There were but six primary admissions on transports for carrierstate.
As would be expected, there were no deaths from this cause.Nine cases were discharged from the service for disability on account of achronic carrier state, eight of which were among white enlisted men and onecolor not stated.
Noneffectiveness caused by carriers was of considerableimportance. For primary admissions to hospitals, Table 36 shows a loss of 98,579days from duty, giving a noneffective ratio per 1,000 per annum of 0.07. Of thetotal number of days lost, white enlisted men where responsible for 91,147 daysand colored 2,127. The remaining days were among soldiers where color was notstated. Time lost in the United States amounted to 51,164 days and in Europe to47,086 days. The noneffective ratio in the United States was 0.06 and in Europe0.08. In other words, cases admitted to hospital in the American ExpeditionaryForces remained absent from duty over a longer period than for the primaryadmissions in the United States. The average number of days of hospitalizationper case in the United States was 16.43 and in Europe 24.64.
Table 37 shows primary admissions for white and coloredtroops, respectively, in the United States and Europe, by months of occurrence;also the ratios per 1,000 per annum. As before stated, it is seen from thistable that the number of cases reported was greater in the United States than inEurope; however, during the latter half of 1918, and for a like period in 1919,the conditions were reversed. This is accounted for by the increase in thediphtheria rate for the army of occupation on the Rhine.
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The number of carriers reported by months shows a distinctseasonal occurrence, which reached its height during the colder months of theyear. This is not true in so far as colored troops were concerned, among whomthe cases reported were only sporadic. The trend is better brought out by thereports of primary admissions of carriers in the United States.
In addition to the 5,043 primary admissions, the carrierstate was reported 2,359 times as a concurrent condition. This makes a total of7,402 carriers reported as patients. It is not believed, however, that 2,359represents the total number of carriers detected among patients during extensiveoutbreaks of diphtheria in our large hospital centers oversea; numerous carrierswere detected, the rush of work preventing recording all such cases.
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At Camp Custer, Mich., Blanton and Burhans3found 148 carriers among 8,236 soldiers examined, or 1.8 per cent. McCord,Friedlander, and Walker8 found 89 contactcarriers among 3,215 soldiers at Camp Sherman, Ohio, or 2.76 per cent. Keefer,Friedberg, and Aronson1 reported 686 carriersamong about 30,000 men cultured at Camp Doniphan. The most extensive report onthe detection of carriers is that of Schorer and Ruddock11from the embarkation and debarkation hospitals, New York City. There, onaccount of the extensive occurrence of diphtheria, routine culturing of allpatients admitted to hospital was deemed necessary. Table 38 shows the resultsof some 50,000 admissions of soldier patients arriving on transports at thisport.
TABLE 38.-Results of cultures for thedetection of diphtheria bacilli among soldiers arrivingatthe port of Hoboken on transports, December, 1918, to May, 1919
| Month |
| Debarkation Hospital | Debarkation Hospital | Embarkation Hospital | ||||||||
| Positive | Per cent | Patients | Positive | Per | Patients | Positive | Per | Patients | Positive | Per | |
December | 4,482 | 34 | .76 | 810 | 14 | 1.73 | 2,261 | 60 | 2.65 | 384 | 2 | 0.52 |
January | 2,958 | 37 | 1.22 | 1,442 | 19 | 1.32 | 2,033 | 59 | 2.41 | 278 | 2 | .72 |
February | 3,198 | 51 | 1.59 | 2,958 | 45 | 1.52 | 1,128 | 17 | 1.51 | 425 | 1 | .24 |
March | 5,651 | 70 | 1.23 | 5,473 | 61 | 1.11 | 1,108 | 5 | .45 | 294 | 1 | .34 |
April | 8,520 | 81 | .95 | 4,047 | 32 | .79 | --- | --- | --- | 438 | 1 | .23 |
May | 2,378 | 19 | .80 | --- | --- | --- | --- | --- | --- | 229 | 1 | .44 |
|
| 27,187 | 292 | 1.07 | 14,730 | 171 | 1.15 | 6,530 | 141 | 2.16 | 2,048 | 8 | .39 |
Grand total: Patients, 50,495; positive, 612;per cent, 1.21
Table 38 shows that the percentage of positive culturesvaried from 0.39 to 2.16. Debarkation Hospital No. 2 served largely as acontagious hospital, Embarkation Hospital No. 4 for officers and nurses, whileDebarkation Hospitals Nos. 3 and 5 were used for general enlisted men'sdebarkation hospitals. The percentage for December, 1918, and January, February,and March, 1919, was higher than during the following April and May. While 1.2per cent of positive cultures is not high, yet the actual number, 612, is largewhen the short period of time and the actual number of exposures are considered.Table 39 shows the relationship between carriers and clinical cases inDebarkation Hospital No. 3.
| Admissions (total) | Carriers | Clinical cases |
1918: |
|
|
|
| December | 4,482 | 34 | 2 |
1919: |
|
|
|
| January | 2,958 | 37 | 13 |
| February | 3,198 | 51 | 20 |
| March | 5,651 | 70 | 30 |
| April | 8,520 | 81 | 17 |
| May 1-15 | 2,378 | 19 | 15 |
In the American Expeditionary Forces, as well as in the United States, thediphtheria carrier was a serious problem in preventive medicine; however,
255
routine culturing of line organizations was not considered practical ornecessary. Upon the appearance of diphtheria, contacts were examined for thedetection of carriers. Messmates, soldiers of the same sleeping quarters (moreespecially those whose beds were adjacent), and members of drill squads wereconsidered contacts for quarantine and culture purposes. The search for carriersin hospitals was usually confined to patients and personnel of the ward wherecases occurred; but in some instances the disease was so widespread that itnecessitated examination of many wards. Reappearance of cases necessitated asecond, or further, culturing for carriers. In Base Hospitals Nos. 25, 26, and45 of the Allerey hospital center, several nurses and enlisted men of theMedical Department were detected as carriers who were known to be carriers inthe United States before departure for overseas, but had been released upon thereport of three negative cultures.2 InBase Hospital No. 25, 75 carriers were found, 331/3per cent of whom gave histories of having been gassed. Since the incubator spacewas limited to 2,000 cultures per day, entire hospital centers were notcultured. It was remarked that it would require about eight days to culture thepopulation of the Allerey hospital center, which approximated 16,000 persons.2Such delay would have resulted in the loss of much of the benefit ofextensive control measures. Some 13,000 cultures were made on selected cases.Carriers in the Savenay hospital center offered the same problem of control.2
Direct or indirect contact with one harboring the organism isnecessary for the development of a carrier. If the strain with which theindividual becomes infected is an avirulent one, or if virulent and theindividual is immune, a carrier state results. Enlarged or diseased tonsils havebeen shown to harbor the germs with great tenacity. The presence of excessivelymphoid tissue in the nasopharynx, atrophic rhinitis, hypertrophied turbinates,deflected nasal septum, or any chronic condition that interferes with nasalventilation predisposes the individual. Empyema of the accessory nasal sinusesand open suppurating wounds of all kinds, at times, show the presence ofvirulent or avirulent diphtheria bacilli. Like the disease itself, diphtheriacarriers are more common during the colder months when respiratory diseases aremost prevalent. Judging from our experience during the World War, carriers aremuch more common. among white persons of the soldier age than among colored.Weaver and Murchie12 cultured the handsof internes and nurses, also door knobs of the hospital, for the purpose ofshowing what part they played in the spread of diphtheria. Hemolyticstreptococci were also looked for during these examinations. The technique wasthat commonly used in isolating these organisms; virulence and antitoxicimmunization tests were also used. Of the persons examined, who came in contactwith diphtheria patients, a total of 268 examinations were made by taking smearsfrom under the fingernails and from the palmar surface of the right indexfinger. Of these 9.3 per cent showed the Streptococcus hemolyticus and 3per cent the diphtheria bacillus. Of 45 nurses, 35.6 per cent showed thestreptococcus and 13.3 per cent the diphtheria bacillus. Among 51 cultures madefrom graduate nurses, specially trained in the care of diphtheria patients andactually engaged in this work, 2 per cent showed the Streptococcushemolyticus and none the diphtheria bacillus. Of 45 cultures made from 3internes,
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15.6 per cent yielded the Streptococcus hemolyticus and6.7 per cent the diphtheria bacillus. Each of the three internes showed thediphtheria bacillus on one occasion after ordinary washing. It was recoveredafter autopsy on a diphtheria case where no rubber gloves were worn. Cultureswere also made from the door knobs in 137 instances. The Streptococcushemolyticus was found in 5.8 per cent and the diphtheria bacillus in 4.4 percent. All of the above examinations were made after ordinary washing with soapand water. Barron and Bigelow4 made 522cultures from the hands of patients, and from fomites in wards containingdiphtheria as well as in wards where no diphtheria was reported. This was donefor the purpose of showing the value and danger of the face mask in the spreadof diphtheria bacilli. The following is a summary of this work:
| Per cent | Exposed wards-Continued. | Per cent |
| Typical B. diptheri?- | Atypical B. diphtheri?- | ||
| On "masked" hands | 6.3 | On "unmasked" hands | 14.9 |
| On "masked" fomites | 8.1 | On "unmasked" fomites | 7.4 |
| Typical B. diphther?- |
| ||
| On "unmasked" hands | 16.1 | Atypical B. diphtheri?- | |
| On "unmasked" fomites | 4.9 | On "unmasked" hands | 5.9 |
| Atypical B. diphtheri?- | On "unmasked" fomites | 5.0 | |
| On "masked" hands | 6.3 |
| |
| On "masked" fomites | 11.7 | ||
"Exposed wards" were wards in which clinical casesof diphtheria or carriers were treated; "unexposed wards" were wardsin which no cases of diphtheria or carriers had been found. The term"masked" means that the patient whose hands or fomites were culturedwore a mask, while "unmasked" means, conversely, that he wore nomask. Typical diphtheria bacilli were found nearly three times as often upon thehands of those not wearing masks as upon those wearing them.
TECHNIQUE OF EXAMINATION FOR CARRIERS
The detection of carriers bacteriologically requires the sametechnique as in the search for cases; however, the taking of specimens differs.In the former, there is usually no acute pathological process as a guide to themost probable site where the organisms may be found and found in greatpreponderance. In routine culturing for carriers a sterile swab is pressed andpassed firmly over the faucial surfaces, particular attention being paid to thetonsils. The swab is then stroked over the surface of a blood serum slant whichis incubated and later examined as in the detection of cases. Additional swabs,made from the nasal passages, increase the percentage of positive cultures. Bothfaucial and nasal smears may be made on the same slant. This method was used insome instances, especially at Camp Doniphan, Okla.,1although it may be said that most medical officers were content with the faucialspecimen, except in selected carriers where the carrier state became chronic andthe focus of infection was sought for.
It was emphasized by medical officers repeatedly during thewar that single cultures, irrespective of the technique used, would reveal onlya portion of the carriers. The percentage varies between wide limits. Amonghealthy
257
persons of various ages, single cultures show from 1 to 30per cent to be carriers, with an average of 3 to 4 per cent, and probably revealless than one-half of the persons infected. As regards the pathology of chroniccarriers, Nichols5 states that amongincubationary carriers the bacilli are found in large numbers at the site of thecommon lesion; in contact carriers nothing specific is found, and among chronicconvalescent carriers the tonsil is by far the most common focus of infection.Occasionally, however, the organisms are found in sinuses or in adenoid tissue.There is no local inflammatory reaction with an outpouring of exudate into thetonsillar crypts; therefore the organisms are not easily detected.
Keefer, Friedberg, and Aronson,1reporting 294 patients at Camp Doniphan, Okla., where the tonsils were removedto relieve the carrier state, found 57 per cent positive and 43 per centnegative in cultures made from the tonsil immediately preceding the operation.Cultures of the tonsils made after tonsillectomy gave positive results in 77.2per cent. They concluded that 22.8 per cent of the cultures were negative andemphasize the importance of not relying upon a single examination. Bloodcultures were made by them from 43 contact throat carriers, 9 convalescentthroat carriers, 3 wound carriers, and 2 wound cases. All were sterile except 1and that may have been a skin contamination. Urine cultures were made fromcentrifugalized specimens of 26 carriers and all were negative. The feces werenegative in all of 21 carriers examined. Simmons, Wearn, and Williams13examined the blood of 25 carriers for isohemagglutinins, according to theMoss classification, with the following results: Group 1, 4 per cent; group 2,24 per cent; group 3, 12 per cent, and group 4, 60 per cent.
Virulence is the most important factor as a guide tosubsequent management. If the carrier is an early convalescent or a contact one,no virulence test is necessary, as most of these strains are virulent; but ifthe carrier state is a long or doubtful one, then virulence tests are indicated.As to retesting for virulence, this is not necessary, since avirulent strainsnever acquire virulence and virulent strains retain their virulence with greattenacity.
Although about 10 per cent of chronic carriers are found toharbor virulent organisms, those who have not been in contact with cases do notseem to be of importance. At camp Custer, Mich., among 148 carriers found, 24strains were recovered and tested for virulence on guinea pigs.3 Ofthese 88 per cent were avirulent. Simmons, Wearn, and Williams,13reporting on the virulence of 52 strains among throat and wound carriers,state that the percentage among contact throat carriers was 48.1 per cent, andfrom convalescent throat carriers 84.6 per cent. Blanton and Burhans3expressed the opinion that too much reliance is probably placed on theso-called "virulence tests."
Duration of the carrier state is either short or prolonged,lasting from a few days to months or years. The average period ofhospitalization for carriers, previously admitted to hospital for thiscondition, was 19.54 days. In the United States the average was 16.43 and in theAmerican Expeditionary Forces, 26.04 days. When analyzed more in detail, it isseen that the duration varied between wide limits. At Camp Custer, Mich., theaverage number of days in hospital among 148 carriers was 11.7 days.3At Camp Doniphan,
258
Okla., it was arbitrarily assumed that the carrier state,among patients convalescing from diphtheria, commenced at the end of the thirdweek of the disease, since the average case becomes bacteria free at that time.1It was found that 91.3 per cent of convalescent carriers became baccillus freeat the end of the second week following tonsillectomy, among 294 carriersoperated upon. The length of time required for the carrier state to end in thedebarkation and embarkation hospitals, New York City,11is shown in Table 40.
| Number of carriers | Period of hospitalization | |||||||||
| 10 to 20 days | 20 days or longer | Grand | ||||||||
Number | Per |
| Number | Per | Average number of days | Number | Per | Average number of days | |||
Hospital Ship O'Reilly | 65 | 30 | 46.1 | 7.8 | 24 | 36.9 | 12.9 | 11 | 18.3 | 22.7 | 12.2 |
Debarkation Hospital No. 1 | 100 | 42 | 42.0 | 6.8 | 35 | 35.0 | 13.7 | 23 | 2.3 | 28.7 | 10.94 |
Debarkation Hospital No. 3 | 276 | 178 | 64.2 | 5.1 | 74 | 26.7 | 12.7 | 15 | 5.4 | 24.4 | 8.0 |
Debarkation Hospital No. 5 | 36 | 32 | 88.8 | 7.0 | 3 | 8.5 | 15.3 | 1 | 2.3 | 22.0 | 8.1 |
Embarkation Hospital No. 4 | 66 | 59 | 89.4 | 8.4 | 7 | 10.5 | 11.8 | --- | --- | --- | 8.8 |
This table includes 543 carriers tabulated by hospital andsubdivided into 3 classes as follows: Less than 10 days; 10 to 20 days; and 30days or longer. It is seen that the averages varied from 8.0 to 12.2 days. Therewere some chronic carriers in all of these hospitals, but officers and nursescleared up quickly. The majority were only temporary carriers. On the hospitalship O'Reilly only 12 per cent cleared up in 12 days or less ascompared with the results of Embarkation Hospital No. 2, where, among 270carriers, but 9 had to remain in isolation for more than 3 days.
As to the handling of diphtheria carriers, during the earliermonths of the war practically all such carriers in the United States werehospitalized, their presence being looked upon with grave apprehension. As timewent on, however, and space in hospitals became less available, it became thepractice to isolate carriers (except incubationary and convalescent) in barracksor tent areas especially set aside for the purpose. Incubationary andconvalescent carriers continued to be cared for in hospital. As soon aspracticable after being quarantined, each carrier was given the Schick test.Contact and chronic carriers showing positive skin tests were immunized,generally with 1,000 units of antitoxin. In rare instances a toxin-antitoxinmixture was used. Pseudocarriers were released as soon as detected. If a carrierstate was a prolonged one, it was often shortened by transfer to hospital fortonsillectomy or virulence testing. In hospitals, carriers were assigned towards where cubicles and masks were used; in barracks, improvised cubicles wereused. The quarantine of contacts was considerably shortened by the use of throatcultures and the Schick test. It was considered safe to release carriers 24hours after all susceptibles had been immunized.
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TREATMENT OF CARRIERS
Various chemicals were used locally to clear up carriers.Tincture of iodine seems to have been the favorite. Diphtheria antitoxin wasused locally and by injection without success. The only local measure that seemsto have met with general favor was tonsillectomy. At Camp Sherman, Ohio,tonsillectomy was performed on a number of cases with prompt results.8 Ofthe 294 carriers treated by tonsillectomny, reported by Keefer, Friedberg, andAronson, 32 per cent had no further positive cultures, while 46.4 per cent werenegative at the end of one week, and 91.3 per cent negative at the end of thesecond week. Striking results were seen after tonsillectomy at Camp Custer.3The consensus of opinion of medical officers seems to have been that inchronic carriers where diphtheria bacilli were located in the tonsils, by farthe best form of treatment is tonsillectomy. This method of treatment could notbe expected to produce favorable results if there were foci of diphtheriabacillus infection elsewhere. Other than this, it may be said that localtreatment was, in general, ineffective in relieving the carrier state.
Briefly, it may be said that carriers of avirulent organismsare harmless and attempts were made to isolate only carriers of virulent bacilli.Appropriate treatment, depending upon the kind of carrier, was given. Forrelease from quarantine, three consecutive negative cultures, without treatment,at daily intervals, or on alternate days, were required. A long protractedisolation was not looked upon with favor unless the organism was a virulent one.
WOUND DIPHTHERIA
Diphtheria bacilli are capable of producing a false membranein wounds. These organisms may exist alone or associated, and it appears that novariety of wound is immune. Wound diphtheria has been reported as complicatingempyema wounds, chronic suppurating wounds in general, especially such asamputations, burns, bites, blisters, contusions following gunshot injuries,compound fractures. Though there is usually a false membrane, diphtheriainfection has been found where no membrane was present. This, however, is theexception. There is usually a fetid, offensive odor, which, too, may be absent.All authors reporting on this subject apparently agree that the diagnosis ofwound diphtheria can not be made with certainty upon clinical grounds alone;nevertheless, any unusual appearance in a surgical wound should lead to abacteriological examination of the discharge; and if an organism is found thatresembles diphtheria morphologically or culturally, virulence tests are calledfor. By this method it can be determined whether the wound infection is reallyof a diphtheritic nature or not. In the diagnosis of suspicious wounds, wherecultures made from surface smears are negative, curettement should be done andsmears taken from a deeper layer.
Hartsell and Morris14 reported upon 60 cases ofwound diphtheria in the Army during the World War. In none of these wounds werethere any systemic symptoms referable to diphtheria toxin. The clinicalappearance of the wound varied; that is to say, 12 per cent showed the grayishmembrane typical of diphtheria; one-half showed only a faint grayishdiscoloration of the granulating surfaces; about 6 per cent looked absolutelyhealthy and ready for
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secondary closure. So far as could be observed, the presenceof diphtheria bacilli in the wound had no effect upon healing. The Schick testwas performed on 43 patients, 6 being positive. The response to treatmentvaried. In some cases the diphtheria bacilli disappeared 2 days after treatment, while in others they were very resistant, ranging to 49 days. By farthe most efficient treatment was tincture of iodine. With this treatment, 15cases cleared up under 48 hours, and only 11 cases remained positive longerthan a week. Antitoxin, in 4 doses of 20,000 units each, was given in 4 cases,but had no effect on ridding the wound of the bacillus. Antitoxin as a wetdressing was also used in two cases without effect. Acetic acid, cauterization,and Carrel-Dakin solution were used without effect.
Keefer, Friedberg, and Aronson, reported an epidemic of wounddiphtheria in two wards of the base hospital at Camp Doniphan, Okla., where ribresections had been made on account of empyema. Between March and May, 1918, 40cases occurred. In 33 cases the diphtheria bacillus was found in the wound,while in 12 it occurred both in the throat and wound of the same individual.Simmons, Wearn, and Williams13 reported diphtheria infections withparticular reference to carriers, and wound infection with diphtheria bacilliat the Walter Reed General Hospital, Washington. They reported that 42 per centof the strains from wound carriers were very virulent, while 80 per cent ofthose from wound cases were very virulent. Neither morphology, fermentationreactions, nor cultural characteristics gave any indication of the degree ofvirulence of the organism studied.
Simmons and Bigelow,14reporting ondiphtheria bacilli in postoperative empyema wounds from the laboratory of theSouthern Department at Fort Sam Houston, Tex., found an organism morphologically like the diphtheria bacillus in 60 healing cases. Of theorganisms isolated, 17.8 per cent were virulent for guinea pigs, and all ofthese strains failed to produce acid when grown on saccharose broth for eightdays. However, the degree of virulence of sugar negative strains was variable.The morphologic characteristics of virulent and avirulent strains were the sameand all cultures contained a mixture of Westbrook's types A, C and D withsubtypes. They found no evidence of the development of specific agglutinins,precipitins, or complement fixation substances for diphtheria bacilli in theserum of infected individuals. Apparently, there is no invasion of the bloodstream by the diphtheria bacillus in wound cases. All methods of treatmentproved unsatisfactory, due probably to the growth of the bacilli deep in thegranulations.
The extent of wound diphtheria in the American ExpeditionaryForces is not known. Barron and Bigelow4 reported its presence at the Allereyhospital center, but the number of cases was not given by them. As a primaryadmission, wound diphtheria was not tabulated on the Army's list of diagnoses;therefore, the total number of cases can not be determined.
The specific treatment of wound diphtheria is that of faucialdiphtheria. The treatment of wound carriers is as unsatisfactory as that ofthroat carriers. Antitoxin, both local and by injection, has been used withoutsatisfactory results for carriers. The unsatisfactory results obtained fromlocal treatment are probably explained by the deep situation of the bacilli. Inthe work of Simmons, Wearn, and Williams,13all methods oftreatment proved to be unsatisfactory, and, as a rule, the carrier state continueduntil complete healing of the wound had taken place.
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REFERENCES
(1) Keefer, F. R.; Friedberg, S. A.; and Aronson, J. D.: A Study of Diphtheria Carriers in a Military camp. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1206.
(2) Neal, M. P., and Sutton, A. C.: Diphtheria in the A. E. F. The Military Surgeon, Washington, 1919, xlv, No. 5, 521.
(3) Blanton, W. B. and Burhans, Chas. W.: A Report of Diphtheria at Camp Custer, Mich., from September, 1917, to March, 1919. The Journal of the American Medical Association, Chicago, lxxii, No. 19, 1355.
(4) Barron, Moses, and Bigelow, Geo. H.: Diphtheria at a Hospital Center. The Journal of Infectious Diseases, Chicago, 1919, xxv, 58.
(5) Nichols, H. J.: Carriers in Infectious Diseases. Williams and Wilkens Co., Baltimore, 1922, 72.
(6) Circular Letter, S. G. O., January 1, 1918.
(7) Weaver, Geo. H.: The Value of the Face Mask and other Measures in Prevention of Diphtheria, Meningitis, Pneumonia, etc. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 2, 76.
(8) McCord, C. P.; Friedlander, A.; and Walker, R. C.: Diphtheria and Diphtheria Carriers in Army Camps. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 4, 275.
(9) Capps, J. A.: A New Adaptation of the Face Mask in Control Contagious Disease. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13, 910.
(10) Haller, D. A., and Colwell, M. C.: The Protective Qualities of the Gauze Face Mask. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1213.
(11) Schorer, E. H., and Ruddock, A. S.: Detection of Carriers and Missed Cases of Diphtheria in Embarkation and Debarkation of Troops. The Military Surgeon, Washington, 1919, xlv, No. 3, 319.
(12) Weaver, Geo. H., and Murchie, J. T.: Contamination of the Hands and Other Objects in the Spread of Diphtheria. Observations on Secondary Infections in Hospitals for Contagious Diseases. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 26, 1921.
(13) Simmons, J. S., Wearn, J. T., Williams, O. B.: Diphtheria Infections, with Particular Reference to Carriers and to Wound Infections with B. diphtheri?. The Journal of Infectious Diseases, Chicago, 1921, xxviii, 327.
(14) Hartsell, J. A., and Morris, M. L.: A Report of Sixty Cases of Wound Diphtheria. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 19, 1351.
(15) Simmons, J. S., and Bigelow, G. H.: Diphtheria Bacilli from Postoperative Empyema Wounds. The Journal of Infectious Diseases, Chicago, 1919, xxv, 219.
