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War Surgery and Medicine

CHAPTER 12 — Diphtheria

page 570


IN the Middle East diphtheria occurred as a seasonal disease during the months of November to March. Among New Zealand troops the incidence was low, except for two epidemics at 1 NZ General Hospital, at Helwan, Egypt, in December 1942, and at Senigallia, Italy, in the winter of 1944–45. In addition there were increased admissions at 2 NZ General Hospital in December 1941 and at 3 NZ General Hospital in February 1944. In the most serious epidemic, that at Senigallia in 1944, when over 150 cases were diagnosed, routine swabbing revealed four carriers on the hospital staff. In connection with the outbreak it was noted that many Italian children were suffering from diphtheria and were in close contact at times with New Zealand troops who were living in houses in the divisional sector. These epidemics involved both faucial and cutaneous diphtheria. In the Middle East true cutaneous diphtheria was rarely found, except in units where faucial infection was also present. Therefore, when diphtheria appeared in a medical unit, carriers (faucial and nasal) had to be sought and wound-dressing technique carefully scrutinised. Preparatory to invaliding to New Zealand by hospital ship in December 1942, a convoy of 161 cases was submitted to routine swabbing of wounds. Twenty-two swabs were returned positive for KLB (Klebs-Loeffler bacilli), but virulence tests were positive in only two cases. These latter cases were temporarily retained in Egypt.

On other occasions, and notably in the outbreak at Senigallia, a number of gunshot wounds were infected and the healing process protracted.

A possible complication in diphtheria cases was post-diphtheritic polyneuritis, of which there were in 2 NZEF 2 cases in 1942, 4 in 1943, 5 in 1944, and 13 in 1945. Though infection of gunshot wounds with the bacillus of diphtheria was rare, except at Senigallia, it was not uncommon to find various skin lesions with an infection of this nature. The organism responsible for the paralysis was found on various occasions in desert sores, the lesion of scabies, or even in an infected pile or ingrowing toenail. page 571 Apart from possible paralysis, it was found the cutaneous diphtheria caused a very great delay in the healing of a wound or lesion. Diphtheria bacilli in wounds caused more than local effects; when toxin was absorbed, paresis and death might follow unless full doses of anti-toxin were given at an early stage.

A full bacteriological examination, including a virulence test of any diphtheria-like organism that might be recovered, was essential in every case before a diagnosis of cutaneous diphtheria could be made. Diphtheroids or diphtheria-like bacilli were commonly found in a variety of superficial skin lesions, and it was most important, therefore, that the virulence of all such organisms should be checked.

On some occasions diphtheritic ulcers could be distinguished by oedema round the wound edges and blackened or yellowish-grey crusts or membrane in the wound, associated with blood-stained sero-purulent discharge and regional lymphadenitis. But clinical appearances were variable and the possibility of diphtheria had always to be remembered, when, after apparent initial healing, a wound developed a serous discharge and became necrotic. In some serious burn cases diphtheritic infection occurred without the characteristic wound appearances.

The incidence of diphtheria among New Zealand troops in the Pacific was low and complications were rare, but tropical ulcers had to be considered a potential diphtheria hazard until proved innocent by appropriate cultures, and, whenever possible, by virulence tests. Several cases of cutaneous diphtheria were diagnosed among patients admitted to 2 NZ CCS from Vella Lavella in January 1944.

Recommendations made by Consultant Physician 2 NZEF in July 1943

The great majority of the cases of diphtheria in this country (Egypt) are mixed infections—diphtheria bacilli and streptococci.

In diagnosis, do not rely upon the appearance of the throat alone. Take everything into consideration—the general condition of the patient, the degree of prostration and the toxaemia, glandular enlargement, albuminuria, the smell of the breath. Give anti-toxin at once, if there is the slightest suspicion of diphtheria. Don't wait for examination of the swab. If the swab should be negative in a suspicious case, ignore it.

Anti-toxin—a single large dose given early is better than repeated smaller doses. Give 40,000 units for an average case and three or four times this dose for a severe case. Anti-streptococcal serum may be required as well, and also sulphanilamide.

page 572

Cutaneous Diphtheria

Has probably been just as commonly the cause of post-diphtheritic paralysis or peripheral neuritis as the faucial type.

Infected sores, desert sores, etc., if there is the slightest suspicion of diphtheria, must be promptly treated with anti-toxin.

It was recognised that the type of diphtheria experienced in the Middle East tended often to be of a very virulent nature, and was readily picked up by those who were susceptible.

In 2 NZEF it was considered desirable that all nursing sisters and voluntary aids should be Schick-tested and, if necessary, immunised. As fresh reinforcements of sisters and nurses arrived overseas from time to time, and as supplies of Schick-testing and immunising material were not always immediately available there, the Consultant Physician 2 NZEF suggested that the immunisation of susceptibles be attended to in New Zealand prior to placing on the overseas roll.

This raises the question of the desirability of immunisation in the future for members of the services, firstly for sisters and voluntary aids, then for other medical personnel and for other service personnel generally.

In November 1943 a nurse died of severe faucial diphtheria, with an associated streptococcal infection complicated by myocarditis and cardiac failure.

There were two deaths, one from diphtheria and one from diphtheritic infection of a wound, in October 1941, and one from diphtheritic polyneuritis in June 1943.

In Italy diphtheria presented peculiar or unusual features, but there were no deaths. For example, multiple ulcers in the natal cleft were found to be due to Klebs-Loeffler infection and cleared up quickly with anti-toxin; a case of faucial diphtheria developed palatal paralysis on the fourth day of his illness; another case treated within twelve hours of onset with ample anti-toxin developed very extensive polyneuritis. The number of hospital admissions in 2 NZEF MEF and CMF, July 1941 to December 1945, recorded were faucial diphtheria, 339; nasal diphtheria, 23; while a group of 180 included unspecified diphtheria, cutaneous cases and carriers. There were four deaths.

Invalided to New Zealand
January 1942 Diphtheria, 1.
January 1945 Ischio-rectal abscess with diphtheritic infection, 1.
February 1945 Diphtheritic infection, 1.
March 1945 Polyneuritis diphtheritic, 1.
January 1946 Diphtheria, faucial, 1.
page 573
Epidemic, 1 NZ General Hospital (Italy)
Faucial Cutaneous Polyneuritis Clinical D Nasal Wound Infections Total
Sep 1944 1 1
Oct 1944 2 3 1
Nov 1944 6 10
Dec 1944 14 3 3
Jan 1945 15 4
Routine Swabbing (Majority Carriers) 3–14 Feb 4 5 17 27
52 16 1 10 20 27 126

Note: Table incomplete—figures not available after 14 February