CHAPTER V_Epidemic Respiratory Disease The pneumonias and other infections of the repiratory tract accompanying influenza and measles

SECONDARY INFECTION IN THE WARD TREATMENT OF MEASLES

JAMES C. SMALL, M.D.

A study of 979 cases of measles was made in the base hospitals of Camps

Funston and Pike from July to December, 1918, with the purpose of

establishing any existing relation between the prevalence of the

hemolytic streptococci and the incidence of the graver complications of

measles, especially the pneumonia following measles. The greater number

of these cases occurred at Camp Pike coincidently with the influenza

epidemic, so that the picture is modified during this period by a

summation of the after effects of the two diseases.

The work undertaken includes:

(a) Routine throat cultures on admission of all patients with measles.

(b) Separation and treatment in separate wards of the patients harboring

hemolytic streptococci and those free from such streptococci.

weekly throat cultures during the period in the hospital.

(d) Bacteriologic study of the complications of measles during life and

at autopsy.

(e) Study of the throat bacteriology of men on duty in the camp, to

establish the prevalence of hemolytic streptococci and of B. influenzæ

in normal individuals.

The work is further divided into that done at Camp Funston during the

latter part of July and throughout August, and that done at Camp Pike

during September, October, November and December, 1918.

=Studies at Camp Funston.=—The work done at Camp Funston is limited

strictly to the identification of hemolytic streptococci in the throats

of all patients with measles coming into the base hospital at Ft. Riley

and to the same study of a group of normal men on duty. During the

period of study hemolytic streptococci were identified by throat culture

in about 1 in 5 of all the normal men examined. Two instances of otitis

media represent the only complications developing in the 112 cases of

measles. Cultures from both patients showed staphylococci. The entire

absence of streptococcus complications appears the more surprising in

view of the fact that the prevalence of hemolytic streptococci among

patients under treatment in the ward was for a time as great as that

among the normal men. No special hospital management was instituted on

the basis of the findings in throat culture. S. hemolyticus carriers

remained in the wards and were treated alongside the “clean” cases. The

sheet cubicle system was used for bed patients. Face masks were not

worn. Convalescent patients were not segregated, and they assisted in

the care of the bed patients and in the ward kitchen. After the initial

throat culture on admission, the throats were gargled with argyrol and

afterwards sprayed with the same solution three times a day. This

solution was also employed to relieve the discomfort caused by the

conjunctivitis during the acute stage of the disease.

=Throat Culture and Identification of Hemolytic Streptococci.=—In

general the methods for the isolation and identification of hemolytic

streptococci as adopted by the Medical Department of the Army were used.

All organisms were isolated in pure culture, grown in broth, examined

microscopically and subjected to tests for hemolysis, (a 5 per cent

suspension of sheep corpuscles being employed), and for bile solubility.

Beef infusion broth and beef infusion agar constituted the two basic

media used. They were prepared so that the finished product titrated

about 0.3 per cent acid to phenolphthalein.

Broth tubes were carried to the bedside. In swabbing, the attempt was

made to produce gagging. This causes the tonsils to protrude from behind

the anterior pharyngeal pillars and places a slight tension on the

capsule which tends to squeeze material from the crypts. The surfaces of

the tonsils thus protruding toward the midline were brushed quickly with

a small cotton swab which was lastly touched to the posterior pharyngeal

wall and withdrawn so as to avoid touching any other parts. The swab was

immediately introduced into a tube of broth, twirled freely under the

surface of the liquid and discarded. The material thus washed into the

broth was carried to the laboratory and kept in the ice box until

plating, which was accomplished with as little delay as possible.

Tubes of melted agar containing 12 c.c. cooled below 45° C., after

receiving 0.6 c.c. of sterile defibrinated horse blood, were inoculated

with a loopful of this broth. Thorough mixing and pouring into Petri

dishes (10 cm. diameter) followed. After cooling, a second loopful was

streaked over the surface of one half of the plate. Deep and superficial

planting were thus effected on the same plate.

This method was found to be very useful. It can be used with advantage

provided one is not called upon to make a great number of cultures when

its time consuming factor is a great inconvenience. Another disadvantage

is the difficulty of picking single colonies for subculture. In spite of

the most careful selection and fishing of a deep colony, subcultures are

less likely to be pure than when surface colonies are chosen. By careful

regulation of the amount of agar in the tubes, the addition of a

measured amount of blood to each enabled one to pour standard blood agar

plates. Uniform thorough mixing of the blood is essential so that the

plate may present the desired “silky” rather than a “curdled” appearance

when viewed by transmitted light.

The plates were incubated eighteen to twenty-four hours when subcultures

in broth were made from the hemolytic colonies. After growing these for

a similar period the additional tests were carried out as indicated

above.

=Hemolytic Streptococci with Measles.=—The incidence of hemolytic

streptococci in the throats of patients with measles admitted to the

base hospital at Ft. Riley was found to be remarkably small.

TABLE LV

HEMOLYTIC STREPTOCOCCI WITH MEASLES IN ALL PATIENTS ADMITTED TO THE

WARDS AT CAMP FUNSTON

═══════════════╤════════╤═══════════╤════════╤════════════╤════════════

│ │APPROXIMATE│ NO. OF │ NO. WITH │ PER CENT

│DAYS IN │ DAY OF │PATIENTS│ HEMOLYTIC │ WITH

│HOSPITAL│ DISEASE │CULTURED│STREPTOCOCCI│ HEMOLYTIC

│ │ │ │ │STREPTOCOCCI

───────────────┼────────┼───────────┼────────┼────────────┼────────────

First Culture │ 0 to 1│ 1 to 8│ 112│ 3│ 2.67

Second Culture │ 3 to 10│ 4 to 16│ 86│ 11│ 12.79

Third Culture │ 8 to 23│ 12 to 26│ 58│ 14│ 24.14

───────────────┴────────┴───────────┴────────┴────────────┴────────────

The first culture represents the findings on admission, in a series of

112 cases; 86 patients being cultured twice; 58 patients three times.

Of the 112 cases examined on admission only 3, or 2.67 per cent were

found to carry hemolytic streptococci. Those patients who were

recultured after from three to ten days in the hospital showed an

incidence of 12.8 per cent. A third culture including patients from

eight to twenty-three days in the hospital, showed an incidence of 24.1

per cent.

=Hemolytic Streptococci in the Throats of Normal Men.=—A total of 274

throat cultures from normal men on duty at Camp Funston (Table LVI)

shows that 21.9 per cent carried hemolytic streptococci at a time when

there were few upper respiratory infections in the camp. A small group

of men resident in the hospital shows a slightly higher prevalence of

hemolytic streptococci (29.3 per cent).

The figures in Table LVI are in sharp contrast with those for measles

patients on admission to the hospital.

TABLE LVI

INCIDENCE OF HEMOLYTIC STREPTOCOCCI, CAMP FUNSTON.

════════════════════════════════════╤════════╤════════════╤════════════

│ │ │ PER CENT

│ │ HEMOLYTIC │ WITH

│ NUMBER │STREPTOCOCCI│ HEMOLYTIC

│EXAMINED│ PRESENT │STREPTOCOCCI

────────────────────────────────────┼────────┼────────────┼────────────

(_a_) White Men: │ │ │

70th Infantry │ 24│ 4│ 16.7

210th Engineers, Co. C │ 26│ 6│ 23.1

164th Depot Brigade, Co. 15 │ 50│ 10│ 20.0

164th Depot Brigade, Co. 18 │ 51│ 13│ 25.5

164th Depot Brigade, Co. 28 │ 50│ 13│ 26.0

Total │ 201│ 46│ 22.9

│ │ │

(_b_) Colored Men, Detention Camp │ │ │

No. 2: │ │ │

164th Depot Brigade, Prov. Co. 22 │ 25│ 6│ 24.0

3d Development Battalion, Co. A │ 24│ 3│ 12.5

3d Development Battalion, Co. D │ 24│ 5│ 20.8

Total │ 73│ 14│ 19.2

│ │ │

(_c_) Men resident in the hospital: │ │ │

Laboratory workers │ 10│ 3│ 30.0

Patients in surgical ward │ 14│ 4│ 28.6

Total │ 24│ 7│ 29.3

────────────────────────────────────┴────────┴────────────┴────────────

Two organizations from which normal men were chosen for examination

furnished a considerable number of cases of measles and offer data

(Table LVII, A and B) for further comparison.

TABLE LVII

A. HEMOLYTIC STREPTOCOCCI WITH MEASLES IN 164TH DEPOT BRIGADE, COMPANY

28.

═══════════════════════════╤════════╤════════╤════════════╤════════════

│ │ │ │ PER CENT

│ │ NO. OF │ NO. WITH │ WITH

│DAYS IN │PATIENTS│ HEMOLYTIC │ HEMOLYTIC

│HOSPITAL│CULTURED│STREPTOCOCCI│STREPTOCOCCI

───────────────────────────┼────────┼────────┼────────────┼────────────

First Culture │ 0 to 1│ 23│ 0│ 0

Second Culture │ 3 to 9│ 23│ 4[90]│ 17.4

Third Culture │10 to 21│ 21│ 4│ 19.05

Normal men of Co. 28 │ │ 50│ 13│ 26.00

───────────────────────────┴────────┴────────┴────────────┴────────────

B. HEMOLYTIC STREPTOCOCCI WITH MEASLES IN SEVENTIETH INFANTRY

───────────────────────────┬────────┬────────┬────────────┬────────────

First Culture │ 0 to 1│ 38│ 0│ 0

Second Culture │ 5 to 9│ 25│ 1│ 4.0

Third Culture │ 8 to 17│ 12│ 2│ 16.7

Normal men on duty with │ │ │ │

70th Infantry │ │ 24│ 4│ 16.7

No one of the 61 cases of measles from the two organizations was found

to be positive on admission to the hospital. Yet among normal men in one

of these organizations the incidence of hemolytic streptococci was 26

per cent and in the other, 16.7 per cent. In both organizations the

incidence among normal individuals compares closely with that of the

patients after a period in the measles wards of the hospital.

=Discussion.=—Three features of the data collected at Camp Funston are

noteworthy. First, the small percentage of S. hemolyticus carriers among

the men admitted to the hospital with measles as compared with the

percentage found in normal men in the camp. Second, the increase in the

number of S. hemolyticus carriers among patients during their stay in

the hospital, the increase continuing until it approaches that of the

normal men on the outside. Third, the prevalence of hemolytic

streptococci in normal throats.

In comparing men arriving at the hospital acutely ill with measles with

normal men in the organization from which they came, only one variable

can be found on which to base the differences observed in the two

groups. This is the advent of the acute disease. The figures seem to

suggest a temporary disappearance of hemolytic streptococci from the

throats of patients acutely ill with measles, at least, to such an

extent that the same cultural methods fail to identify the organisms.

The increase in the S. hemolyticus carriers among patients with measles

after a period in the hospital might depend upon two factors: First, the

exposure to contact infections in the hospital ward, depending on the

length of time in the ward as well as on the character of the ward

management; second, the passing of the acute stage of measles with a

return of the bacterial flora of the throat to the condition existing

before the onset of the acute disease. The first appears the more

probable. The second has only the support of the observation that the

streptococci were absent from the throat during the acute stage of

measles or were much less frequently found in patients with measles than

in normal men and later their incidence approached that in normal

individuals. The rather high incidence of hemolytic streptococci in

normal men at Camp Funston may have been due to the very recent

assembling of the 10th Division which now occupied the camp. It is

probable that the housing of large numbers of men in barracks is

attended by the same contact dissemination of mouth organisms that

occurs in hospital wards.

=Measles at Camp Pike.=—All cases of measles coming into the base

hospital at Camp Pike between September 15 and December 15, 1918, a

total of 867 cases, are included in the report. Upon the arrival of the

commission at Camp Pike early in September, a plan for the separation of

cases carrying hemolytic streptococci and those free from these

organisms was put into operation. The preliminary arrangements included

the allotment of suitable wards for treatment of the different classes

of cases; a throat culture survey of all patients with measles under

treatment at the time; their separation in accordance with the results

of bacteriologic examination, and the transfer of each group of patients

to its designated ward. By September 15 these preliminary arrangements

had been completed. Cases of measles admitted on this date and

afterwards were held in an observation ward pending the report upon a

throat culture before they were transferred to the treatment wards.

Beginning September 15 the following system of handling measles cases

was maintained in the wards of the base hospital.

All patients were received in an observation ward where they remained

until the results of a throat culture for hemolytic streptococci could

be reported back to the ward. Cases reported positive or negative were

immediately transferred to their respective treatment wards. All

patients in the treatment wards were cultured at intervals of one week

and cases found positive were transferred from the “clean” treatment

wards to a treatment ward for cases carrying hemolytic streptococci. The

ward personnel attending patients in the “clean” treatment wards was

examined by throat cultures from time to time with the purpose of

eliminating S. hemolyticus carriers. Patients segregated in the

streptococcus wards remained there, if uncomplicated, throughout their

hospital treatment even though subsequent repeated throat cultures

showed that the carrier condition had disappeared. Two wards were

provided to care for the pneumonia following measles. One received only

patients whose throat cultures were negative for hemolytic streptococci;

the other, those positive. It is essential that the throat culture on

which this differentiation is made be taken as soon as the complication

is reported and that transfer be made promptly on receipt of the report

of the culture. To facilitate this transfer, cases of pneumonia

complicating measles were reported to the laboratory as soon as

diagnosed and cultures were taken at once. The case remained in the

measles ward during twenty-four hours, isolated as well as possible,

awaiting report of culture before transfer. Within the positive ward for

measles pneumonias, distinction was made between streptococcus

pneumonias and nonstreptococcus pneumonias harboring hemolytic

streptococci in their throats. The two classes of cases were treated in

separate sections of the ward.

Ear complications were seen and treated by medical officers from the

otological service. These patients remained in the measles wards while

in the acute stage of measles, but later were transferred to the service

of otology whenever further surgical treatment became necessary.

Within the individual wards for treatment of measles and measles

pneumonias, precautions for minimizing the dangers of contact infections

were carried out as well as possible. Throughout the study we had the

hearty cooperation of the base hospital authorities and earnest,

well-directed effort to perfect ward management on the part of the ward

surgeons and their staffs. Difficulties encountered during the emergency

created by the sudden explosion of the influenza epidemic, in spite of

the best efforts of all, did much to disrupt the plan which had been

instituted for the control and study of the complications of measles.

Scarcely had wards been designated and all measles patients on hand

differentially allotted to them, when the influenza epidemic appeared

and quickly filled the hospital beyond its capacity. Measles wards were

taken over for the care of influenza patients. Measles patients, of

which there were not a great number at the time, were necessarily

crowded together, so that compartments of wards instead of separate

wards had to be used in maintaining our separation of the two groups of

patients. While the base hospital was yet filled with patients with

influenza and influenza pneumonia, admission of patients with measles

increased, so that one ward after another was reclaimed for the care of

this disease. During this period the measles wards were at times

overcrowded and the strictest ward technic could not be practiced. Again

new wards were, on occasions, partly filled by admission and transfer

before they were properly equipped to receive patients. This

disorganization was directly due to the necessity of treating a rapidly

increasing number of measles patients before the hospital was cleared of

patients with influenza and pneumonia. After this emergency, the system

of ward management was rapidly readjusted, and admissions were limited

to the normal capacities of the wards.

The cubicle system was used in all wards. Bed patients were not required

to wear masks, but the mask was strictly enforced upon all patients

leaving the cubicle. All attendants were required to wear gowns, caps

and masks while in the wards. An attempt was made to prevent the

congregating of convalescents. Guards were posted at the latrine doors

to limit admission to the capacity of the latrine. Borrowing and lending

of any materials between patients were strictly forbidden. Paper sputum

cups were provided, kept clean and covered. In the measles pneumonia

wards hand disinfectant solutions were provided for use by attendants

when they passed from one patient to another. The ward floors were

scrubbed at intervals with lysol in water. Dry sweeping of the wards in

the morning is regrettable.

=Bacteriologic Methods Used in the Study.=—The methods used for the

identification of hemolytic streptococci here were essentially the same

as those used at Camp Funston and described above, the one exception

being the use of surface cultures on blood agar instead of the combined

surface and deep culture. Blood agar plates containing 5 per cent

defibrinated horse blood were poured and used while fresh. The throat

swabs were carried to the laboratory in sterile test tubes. The plates

were inoculated by touching the swab lightly to the surface of the agar

plate at two places, one near either extremity of a given diameter of

the plate. On touching the swab to the agar, the swab stick was rolled

between the fingers so as to turn it through one revolution and thereby

bring all points of the circumference of the cotton swab in contact with

the agar surface.

The material thus inoculated on the plates was spread by means of a

platinum wire slightly turned over at the end in “hockey stick” fashion.

The wire was passed back and forth several times over the point of

inoculation and then multiple streaks and cross streaks were made over

the agar surface. The initial contact of the wire with the point of

inoculation was not repeated. The cross streaking serves to spread and

distribute this material evenly over the surface. Well seeded plates by

this multiple streak method are the rule and the uniform distribution of

well separated colonies over the surface makes it very easy to pick pure

cultures, and renders plate reading easy.

Very early in the course of our study of throat cultures at Camp Pike,

the great frequency of abundant growths of B. influenzæ was observed.

Consequently, the throat cultures of all measles patients examined from

September 15 to October 20 were studied for the identification of B.

influenzæ. In all cases identification was based on the cultural,

staining and morphologic characteristics. Tests for growth on hemoglobin

free media were not made as a routine.

=Relation of Measles and Pneumonia Following Measles to the Influenza

Epidemic.=—The influenza epidemic at Camp Pike was recognized on

September 23 because of an alarming increase of hospital admissions. It

ran its brief course, and ten days later, October 3, the decline began.

The first four days of October rank highest in admissions of patients

with pneumonia following influenza. The onset of 20 scattered cases of

measles occurred before September 25, and later the number slowly

increased reaching its height about the middle of October; after this

time a gradual decline began, and continued during about three weeks

before the preepidemic level was reached. During this period of six

weeks following September 25, 709 cases of measles occurred.

TABLE LVIII

ONSET OF MEASLES AND OF PNEUMONIA FOLLOWING MEASLES BY WEEKS FROM

SEPTEMBER 11 TO DECEMBER 11, 1918

═══════════════════════╤═══════════════════════╤═══════════════════════

DATES │ MEASLES │ PNEUMONIA FOLLOWING

│ │ MEASLES

───────────────────────┼───────────────────────┼───────────────────────

Sept. 11 to 17 │ 18│ 0

Sept. 18 to 24 │ 20│ 0

Sept. 25 to Oct. 1 │ 74│ 0

Oct. 2 to 8 │ 143│ 13

Oct. 9 to 15 │ 178│ 9

Oct. 16 to 22 │ 158│ 16

Oct. 28 to 29 │ 100│ 6

Oct. 30 to Nov. 5 │ 56│ 3

Nov. 6 to 12 │ 38│ 4

Nov. 13 to 19 │ 23│ 1

Nov. 20 to 26 │ 29│ 1

Nov. 27 to Dec. 3 │ 22│ 1

Dec. 4 to 10 │ 8│ 1

Dec. 11 │ 0│ 1

───────────────────────┴───────────────────────┴───────────────────────

Pneumonia following measles began to appear on October 5, and within the

week following 16 cases occurred. An equal number of cases appeared each

week during about three weeks and fewer scattered cases occurred

throughout November and December. Table LVIII shows date of onset of

measles and measles pneumonia cases.

Chart 3 presents the occurrence of measles and of the pneumonia

following measles by weeks of onset compared with that of epidemic

influenza.

[Illustration:

Chart 3.—Shows the relation of the epidemic of measles to that of

influenza at Camp Pike, and the relations of the pneumonia following

measles to both measles and influenza. The large incomplete curve

represents influenza; the intermediate curve, measles; the small

curve, pneumonia following measles.

]

It will be noted from the overlapping of the two curves in Chart 3 that

a considerable portion of the measles cases appeared before the

influenza had subsided in Camp Pike. This occurrence of the two

epidemics at the same time makes it impossible to separate the parts

played by each disease in producing the pneumonias and other

complications following measles. Analysis of the chart, however, shows

that the pneumonia with measles occurred in large part during the first

half of the measles epidemic. This is of particular significance since

it was during this period that the effects of the influenza wave were

felt most severely.

In Table LIX the cases of measles are grouped into fifteen day periods

according to their dates of onset and the pneumonias arising from each

group are tabulated. This tabulation shows very clearly that the

pneumonia complications developed in large part in patients with measles

entering the hospital during the influenza period, that is, late in

September and during the first half of October.

TABLE LIX

PATIENTS WITH MEASLES AND WITH SUBSEQUENT PNEUMONIA

═════════════════╤═════════════════╤═════════════════╤═════════════════

DATES │ TOTAL CASES OF │ TOTAL CASES │ OF PER CENT

│ MEASLES DURING │ PNEUMONIA FROM │ INCIDENCE OF

│ INTERVALS OF 15 │ SAME │ PNEUMONIAS

│ DAYS │ │

─────────────────┼────────┬────────┼────────┬────────┼────────┬────────

Sept. 11 to 30 │ 86│ 433│ 14│ 42│ 16.28│ 9.7%

Oct. 1 to 15 │ 347│ „ │ 28│ „ │ 8.07│ „

─────────────────┼────────┼────────┼────────┼────────┼────────┼────────

Oct. 16 to 31 │ 270│ 434│ 8│ 14│ 2.96│ 3.2%

Nov. 1 to 15 │ 91│ „ │ 2│ „ │ 2.2│ „

Nov. 16 to 30 │ 56│ „ │ 4│ „ │ 7.15│ „

Dec. 1 to 15 │ 17│ „ │ 0│ „ │

─────────────────┴────────┴────────┴────────┴────────┴─────────────────

The high incidence of pneumonia among measles patients coming into the

hospital prior to, with, or immediately following the height of the

influenza epidemic is very striking. It so happens that half of the

total number of measles cases considered, date their onsets prior to

October 15. From the 433 cases included in this first half, 42 cases of

pneumonia arose, while from the 434 cases arising during the two months

following October 15, only 14 or one-third as many cases of pneumonia

developed. These figures very strongly suggest that influenza played a

large part in the production of the pneumonia with measles in this group

of cases.

Again the 9.7 per cent incidence of pneumonia in the first half of cases

considered, approaches the 12 per cent incidence of pneumonia following

influenza observed in the epidemic at Camp Pike, while the incidence of

3.2 per cent in the second half of the cases conforms more nearly to

figures for pneumonia following measles in the army prior to the

pandemic of influenza.

It has been shown that the prevalence of B. influenzæ at Camp Pike

increased with the passing of the wave of influenza (p. 40) and that

this increase applied to the measles admissions. For a time the

separation of measles patients carrying B. influenzæ as identified by

throat culture on admission, from those free from it, was practiced. All

cases were then followed up by weekly throat cultures, and cases in

negative wards on being identified as positives were transferred.

This practice was discontinued as impractical when it became apparent

that about 80 per cent of patients with measles would be found positive

for B. influenzæ when repeated throat cultures were made during their

hospital treatment. The dissemination of B. influenzæ through the wards

from which we were attempting to exclude it took place much faster than

we could follow its spread by cultural methods. When this became

evident, the practice of separating the two groups of patients with

reference to B. influenzæ was discontinued and the great inconvenience

of repeated transfer of patients was largely eliminated.

Table LX gives the findings in 426 cases of measles cultured for B.

influenzæ during the period when the practice of separating measles

patients carrying B. influenzæ from those not carrying the organisms was

followed.

TABLE LX

RESULTS OF REPEATED THROAT CULTURES FOR B. INFLUENZÆ ON 426 CASES OF

MEASLES, CAMP PIKE, SEPT. 15 TO OCT. 20, 1918.

═══════════╤════════╤═════════╤═════════════════════════════════════

│ │ │

│ │GROUP NO.│

│ TOTAL │NEGATIVE │

GROUPS │ NUMBER │ FOR B. │ RESULTS OF CULTURES TO DATE

│CULTURED│INFLUENZÆ│

│IN GROUP│ ON │

│ │ADMISSION│

│ │ │

───────────┼────────┼─────────┼───────┬───────┬───────┬───────┬─────

│ │ │ │ │ │ │ NO.

„ │ „ │ „ │ 1ST │ 2ND │ 3RD │ 4TH │ IN

│ │ │CULTURE│CULTURE│CULTURE│CULTURE│EACH

│ │ │ │ │ │ │CLASS

───────────┼────────┼─────────┼───────┼───────┼───────┼───────┼─────

I │ │ │ │ │ │ │

1st culture│ │ │ │ │ │ │

on │ 426│ ——│ − │ │ │ │ 274

admission│ │ │ │ │ │ │

„ │ „ │ „ │ + │ │ │ │ 152

II │ │ │ │ │ │ │

1st and 2nd│ │ │ │ │ │ │

culture, │ │ │ │ │ │ │

after one│ 201│ 143│ − │ − │ │ │ 75

week in │ │ │ │ │ │ │

hospital │ │ │ │ │ │ │

„ │ „ │ „ │ − │ + │ │ │ 68

„ │ „ │ „ │ + │ + │ │ │ 29

„ │ „ │ „ │ + │ − │ │ │ 29

III │ │ │ │ │ │ │

1st, 2nd │ │ │ │ │ │ │

and 3rd │ │ │ │ │ │ │

cultures │ 94│ 69│ − │ − │ − │ │ 22

after two│ │ │ │ │ │ │

weeks in │ │ │ │ │ │ │

hospital │ │ │ │ │ │ │

„ │ „ │ „ │ − │ − │ + │ │ 18

„ │ „ │ „ │ − │ + │ − │ │ 13

„ │ „ │ „ │ − │ + │ + │ │ 16

„ │ „ │ „ │ + │ + │ + │ │ 8

„ │ „ │ „ │ + │ − │ + │ │ 6

„ │ „ │ „ │ + │ + │ − │ │ 4

„ │ „ │ „ │ + │ − │ − │ │ 7

IV │ │ │ │ │ │ │

1st, 2nd, │ │ │ │ │ │ │

3rd and │ │ │ │ │ │ │

4th │ │ │ │ │ │ │

cultures │ 25│ 19│ − │ − │ − │ − │ 4

after │ │ │ │ │ │ │

three │ │ │ │ │ │ │

weeks in │ │ │ │ │ │ │

hospital │ │ │ │ │ │ │

„ │ „ │ „ │ − │ − │ − │ + │ 3

„ │ „ │ „ │ − │ − │ + │ + │ 3

„ │ „ │ „ │ − │ − │ + │ − │ 2

„ │ „ │ „ │ − │ + │ + │ + │ 2

„ │ „ │ „ │ − │ + │ − │ + │ 2

„ │ „ │ „ │ − │ + │ + │ − │ 2

„ │ „ │ „ │ − │ + │ − │ − │ 1

„ │ „ │ „ │ + │ + │ + │ + │ 2

„ │ „ │ „ │ + │ − │ − │ + │ 1

„ │ „ │ „ │ + │ − │ + │ + │ 1

„ │ „ │ „ │ + │ + │ + │ − │ 1

„ │ „ │ „ │ + │ − │ − │ − │ 1

───────────┴────────┴─────────┴───────┴───────┴───────┴───────┴─────

═══════════╤════════╤══════════╤════════╤═════════

│ │ GROUP OF │ │GROUP PER

│ │POSITIVES │ │ CENT OF

│ GROUP │DEVELOPING│PER CENT│POSITIVES

│ NO. │TO DATE IN│OF GROUP│ TO DATE

GROUPS │POSITIVE│ CASES │POSITIVE│ AMONG

│ FOR B. │ NEGATIVE │ FOR B. │ CASES

│INF. TO │ FOR B. │INF. TO │NEGATIVE

│ DATE │ INF. ON │ DATE │ FOR B.

│ │ADMISSION │ │ INF. ON

│ │ │ │ADMISSION

───────────┼────────┼──────────┼────────┼─────────

│ │ │ │

„ │ „ │ „ │ „ │ „

│ │ │ │

───────────┼────────┼──────────┼────────┼─────────

I │ │ │ │

1st culture│ │ │ │

on │ 152│ ————│ 35.6│ ————

admission│ │ │ │

„ │ „ │ „ │ „ │ „

───────────┼────────┼──────────┼────────┼─────────

II │ │ │ │

1st and 2nd│ │ │ │

culture, │ │ │ │

after one│ 126│ 68│ 62.7│ 47.5

week in │ │ │ │

hospital │ │ │ │

„ │ „ │ „ │ „ │ „

───────────┼────────┼──────────┼────────┼─────────

III │ │ │ │

1st, 2nd │ │ │ │

and 3rd │ │ │ │

cultures │ 72│ 47│ 77.7│ 68.1

after two│ │ │ │

weeks in │ │ │ │

hospital │ │ │ │

„ │ „ │ „ │ „ │ „

───────────┼────────┼──────────┼────────┼─────────

IV │ │ │ │

1st, 2nd, │ │ │ │

3rd and │ │ │ │

4th │ │ │ │

cultures │ 21│ 15│ 84│ 79.

after │ │ │ │

three │ │ │ │

weeks in │ │ │ │

hospital │ │ │ │

„ │ „ │ „ │ „ │ „

───────────┴────────┴──────────┴────────┴─────────

On admission 35.6 per cent of the patients were found positive for B.

influenzæ. Repeated throat cultures were not confined to those appearing

negative on this initial culture, but were made on all patients without

regard to their being previously positive or negative. By a summation of

the results of the weekly cultures of all patients, the percentage of

patients carrying B. influenzæ rises from 35.6 per cent on admission, to

62.7 per cent after one week; to 77.7 per cent after two weeks; to 84

per cent after three weeks in the hospital.

To gain some idea of the rate of spread of B. influenzæ in wards

receiving only patients whose throat cultures were negative for B.

influenzæ on admission, a similar summation of the results of repeated

throat cultures on patients in negative wards shows weekly increases

from 47.5 per cent after one week, to 68.1 per cent after two weeks; to

79 per cent at the end of three weeks.

These results demonstrate quite clearly that the measles wards were

saturated with B. influenzæ during the period of the influenza epidemic.

Conditions within the measles wards with regard to B. influenzæ were not

at all different from those in the camp community during this period.

While no clinical methods could be relied upon to diagnose influenza in

the presence of an acute attack of measles, there is every reason to

believe that the occurrence of clinical influenza with measles was no

less frequent than was its incidence in the camp at large, that is,

about 20 to 25 per cent. That influenza played a large part in

determining predisposition to the complications of measles in this

series seems evident.

Hemolytic Streptococci with Measles at Camp Pike

Between September 15 and December 15, 1918, 867 cases of measles,

admitted to the wards of the base hospital, were studied and handled

according to the system outlined above. About one half of these cases

appeared during the first month of the study. During this month

hemolytic streptococci played a very insignificant rôle. This

microorganism did not appear with alarming prevalence until after the

wards had been thoroughly overcrowded. After the emergency, when better

ward conditions were provided, S. hemolyticus carriers continued to

develop in the wards and were removed when identified. The first S.

hemolyticus carriers to develop in the wards were identified on October

8. The first case of streptococcus pneumonia developed on October 17,

while streptococcus otitis as a complication of measles did not begin

until a little later. During the latter two months of the study, S.

hemolyticus became rampant in the wards. The streptococcus complications

date their onset at some time during these two months.

Table LXI shows the number of admissions to the measles wards by weeks

and the patients among them found to be carrying hemolytic streptococci.

It also shows the number of S. hemolyticus carriers developing each week

among patients under treatment in the “clean” wards, as identified by

throat cultures repeated at weekly intervals. For purposes of

orientation, the number of cases developing streptococcus pneumonia and

otitis media with its subsequent mastoiditis are given for each week

during the period of observation.

An admission to the measles ward can generally be regarded as an acute

case of measles. There are a few exceptions to this statement and these

are cases of measles treated in barracks and afterwards transferred to

the base hospital. A relatively small number of such cases furnished 16

of the cases positive for hemolytic streptococci on admission to the

measles ward.

TABLE LXI

S. HEMOLYTICUS CARRIERS IDENTIFIED BY THROAT CULTURE AMONG ADMISSIONS; THOSE

DEVELOPING AMONG PATIENTS UNDER TREATMENT IN THE STREPTOCOCCUS “CLEAN”

MEASLES WARDS; S. HEMOLYTICUS COMPLICATIONS ACCORDING TO THEIR DATES OF ONSET

════════╤══════════════════════╤══════════════════════╤══════════════════════

GROUPING│ │HEMOLYTIC STREPTOCOCCI│ PRINCIPAL

OF CASES│ ADMISSION CASES │ HOSPITAL CASES │ COMPLICATIONS DUE TO

BY WEEKS│ │ DEVELOPING │ HEM. STREP.

────────┼────────┬──────┬──────┼────────┬──────┬──────┼──────┬──────┬────────

„ │ │ NO. │ PER │ │ NO. │ PER │ │ │

│ NO. │ POS. │ CENT │ NO. │ POS. │ CENT │ │ │MASTOID-

│ CASES │ HEM. │ POS. │ CASES │ HEM. │ POS. │PNEUM.│OTITIS│ ITIS

│CULTURED│STREP.│ HEM. │CULTURED│STREP.│ HEM. │ │ │

│ │ │STREP.│ │ │STREP.│ │ │

────────┼────┬───┼───┬──┼──────┼────────┼──────┼──────┼──────┼──────┼────────

Sept. 15│ │ │ │ │ │ │ │ │ │ │

to │ 23│252│ 1│ 3│ 1.2│ 0│ 0│ 0│ 0│ 0│ 0

Sept. │ │ │ │ │ │ │ │ │ │ │

21 │ │ │ │ │ │ │ │ │ │ │

Sept. 22│ │ │ │ │ │ │ │ │ │ │

to │ 25│ „ │ 1│„ │ „ │ 23│ 0│ 0│ 0│ 0│ 0

Sept. │ │ │ │ │ │ │ │ │ │ │

29 │ │ │ │ │ │ │ │ │ │ │

Sept. 30│ │ │ │ │ │ │ │ │ │ │

to │ 95│ „ │ 0│„ │ „ │ 24│ 0│ 0│ [91]1│ 0│ 0

Oct. 6│ │ │ │ │ │ │ │ │ │ │

Oct. 7 │ │ │ │ │ │ │ │ │ │ │

to │ 109│ „ │ 1│„ │ „ │ 121│ 4│ 3.3│ 0│ 0│ 0

Oct. │ │ │ │ │ │ │ │ │ │ │

13 │ │ │ │ │ │ │ │ │ │ │

────────┼────┼───┼───┼──┼──────┼────────┼──────┼──────┼──────┼──────┼────────

Oct. 14 │ │ │ │ │ │ │ │ │ │ │

to │ 223│494│ 7│19│ 3.8│ 175│ 8│ 4.6│ 1│ 0│ 0

Oct. │ │ │ │ │ │ │ │ │ │ │

20 │ │ │ │ │ │ │ │ │ │ │

Oct. 21 │ │ │ │ │ │ │ │ │ │ │

to │ 156│ „ │ 5│„ │ „ │ 451│ 35│ 7.7│ 2│ 3│ 0

Oct. │ │ │ │ │ │ │ │ │ │ │

27 │ │ │ │ │ │ │ │ │ │ │

Oct. 28 │ │ │ │ │ │ │ │ │ │ │

to │ 71│ „ │ 6│„ │ „ │ 333│ 29│ 8.7│ 1│ 12│ 1

Nov. 3│ │ │ │ │ │ │ │ │ │ │

Nov. 4 │ │ │ │ │ │ │ │ │ │ │

to │ 44│ „ │ 1│„ │ „ │ 263│ 45│ 17.1│ 3│ 8│ 11

Nov. │ │ │ │ │ │ │ │ │ │ │

10 │ │ │ │ │ │ │ │ │ │ │

Nov. 11 │ │ │ │ │ │ │ │ │ │ │

to │ 31│117│ 4│13│ 11.1│ 149│ 46│ 30.8│ 0│ 5│ 5

Nov. │ │ │ │ │ │ │ │ │ │ │

17 │ │ │ │ │ │ │ │ │ │ │

Nov. 18 │ │ │ │ │ │ │ │ │ │ │

to │ 41│ „ │ 4│„ │ „ │ 93│ 7│ 7.5│ 0│ 2│ 2

Nov. │ │ │ │ │ │ │ │ │ │ │

24 │ │ │ │ │ │ │ │ │ │ │

Nov. 25 │ │ │ │ │ │ │ │ │ │ │

to │ 19│ „ │ 0│„ │ „ │ 48│ 7│ 14.6│ 0│ 3│ 2

Dec. 1│ │ │ │ │ │ │ │ │ │ │

Dec. 2 │ │ │ │ │ │ │ │ │ │ │

to │ 26│ „ │ 5│„ │ „ │ 52│ 12│ 23.1│ 0│ 3│ 0

Dec. 8│ │ │ │ │ │ │ │ │ │ │

Dec. 9 │ │ │ │ │ │ │ │ │ │ │

to │ 4│ │ 2│ │ │ 47│ 12│ 25.5│ 1│ 0│ 0

Dec. │ │ │ │ │ │ │ │ │ │ │

15 │ │ │ │ │ │ │ │ │ │ │

────────┴────┴───┴───┴──┴──────┴────────┴──────┴──────┴──────┴──────┴────────

An admission to the measles ward does not indicate admission to the

hospital, because a considerable number of cases of measles developed

from time to time among patients under treatment in the hospital for

other conditions. Since these patients remained in other wards not

subject to the same ward management and with no distinction between

those positive and those negative for hemolytic streptococci, they

cannot be included in figures to show the incidence of hemolytic

streptococci in patients with measles at the time of admission to

hospital from the camp. Two classifications of the 37 cases, positive

when first observed, are necessary.

1. Division of cases according to days in the hospital before first

culture was taken:

Days in Hospital No. of cases

0–1 (admission) 15 (2 not acute)

2–7 10

More than 7 12

2. Classification according to stage of the disease:

During acute stage 21 cases

After acute stage 16 cases

The first classification shows only 13 cases positive when cultured on

admission to the hospital and also during the acute stage of the

disease; the incidence of S. hemolyticus in patients on admission is

very low (1.76 per cent).

The second classification shows a slightly higher incidence for cases

during the acute stage of the disease, regardless of whether they were

admitted to the measles service from camp or from another service of the

hospital (2.4 per cent). These findings conform with those at Fort Riley

in a smaller series of cases and support the opinion that the hemolytic

streptococci temporarily disappear from the throat during the acute

onset of measles. Unfortunately controls among normal men in Camp Pike

were not taken at intervals throughout the period of three months

represented by this study of measles, but all controls taken show a

higher incidence than that found among measles patients on admissions

over a period of time comparable to that of the control series.

The gradual increase in the percentage of patients developing hemolytic

streptococci in their throats in wards receiving only streptococcus free

cases demonstrates that the admission culture and the subsequent weekly

cultures, with the separation of all patients identified as carriers,

did not suffice to control the spread of streptococcus in this group of

cases. It is interesting to note that the greatest incidence of

streptococcus carriers among these patients occurred three weeks after

the height of the measles epidemic, when it became about four times that

observed at the height of the measles epidemic.

When we consider the time relations of the streptococcus complications,

it is noteworthy that they begin to appear somewhat after the appearance

of streptococcus carriers and then increase parallel with the increase

in the numbers of carriers. The relative number of complications

developing among the first carriers which were identified is less than

that among the carriers appearing later. This suggests an increase in

virulence of hemolytic streptococci attending their wider dissemination.

Tables LXII and LXIII are introduced for the purpose of showing to what

extent duration of stay in the hospital increases the individual’s

chances of acquiring hemolytic streptococci. Table LXII includes all

cases admitted to and treated in the measles wards. On repeated

cultures, previous positives and negatives were cultured alike and the

total positives reported for each week.

Table LXIII includes only those cases treated in the “clean” wards and

known to be negative on previous culture.

TABLE LXII

INCIDENCE OF HEMOLYTIC STREPTOCOCCI IN THROATS OF MEASLES CASES WITH

REFERENCE TO PERIOD IN HOSPITAL

(All cases treated in the wards)

PERIOD IN MEASLES│ NO. CASES │NO. POSITIVE FOR │PER CENT POSITIVE

WARD │ CULTURED │ HEMOLYTIC │ FOR HEMOLYTIC

│ │ STREPTOCOCCI │ STREPTOCOCCI

─────────────────┼─────────────────┼─────────────────┼─────────────────

(Admission) │ 867│ 37│ 4.2

1 week│ 768│ 84│ 10.9

2 weeks│ 479│ 109│ 22.8

3 weeks│ 240│ 63│ 26.2

4 weeks│ 133│ 44│ 33.1

5 weeks│ 82│ 26│ 31.7

6 weeks│ 53│ 14│ 26.4

7 weeks│ 25│ 8│ 32.0

8 weeks│ 13│ 1│ 7.7

9 weeks│ 9│ 1│ 11.1

10 weeks│ 6│ 0│ 0

11 weeks│ 5│ 0│ 0

─────────────────┴─────────────────┴─────────────────┴─────────────────

TABLE LXIII

WEEKLY DEVELOPMENT OF HEMOLYTIC STREPTOCOCCI IN THROATS OF PATIENTS

TREATED IN “CLEAN” WARDS

PERIOD IN MEASLES│ NO. CASES │NO. POSITIVE FOR │PER CENT POSITIVE

WARD │ CULTURED │ HEMOLYTIC │ FOR HEMOLYTIC

│ │ STREPTOCOCCI │ STREPTOCOCCI

1 week│ 738│ 67│ 9.1

2 weeks│ 424│ 74│ 17.4

3 weeks│ 195│ 34│ 17.4

4 weeks│ 92│ 16│ 17.4

5 weeks│ 46│ 7│ 15.2

6 weeks│ 26│ 4│ 15.4

7 weeks│ 14│ 3│ 21.4

8 weeks│ 8│ 0│

9 weeks│ 5│ 0│

10 weeks│ 4│ 0│

11 weeks│ 3│ 0│

A comparison of Tables LXII and LXIII gives some indication of what

might have been expected if the carriers had not been removed from the

treatment wards at weekly intervals. With the carriers removed from the

“clean” cases and segregated in a separate ward so as to be removed

effectively as sources of spread of the S. hemolyticus infection to

clean cases, the percentage incidence with all cases considered rose to

a point nearly twice as high as that ever reached in the wards where

clean cases alone were allowed to remain. Had these carriers not been

separated, and remained in contact with cases free from hemolytic

streptococci, they would have served as just so many more sources of

infection, and an incidence of at least twice that recorded for all

cases combined, or four times that of the treatment wards, might have

been expected. These results indicate that the weekly separation of

carriers from clean cases did, to a considerable extent, lower the

individual’s danger of acquiring S. hemolyticus infection while in the

hospital.

Complications of Measles

In Table LXIV the complications developing in the measles patients under

observation at Camp Pike are tabulated. In the division of the

complications developing in “carriers” and “noncarriers” of the

hemolytic streptococci, reference is made only to the records of the

throat cultures. The division is therefore not dependent upon the

bacteriology of the complications. For example, only 9 of the 12 cases

of pneumonia developing in “carriers” were streptococcus pneumonias. On

the other hand, the cases of mastoiditis following otitis media were

almost invariably due to hemolytic streptococci. Of the 10 otitis cases

occurring in “noncarriers,” 4 developed mastoiditis and 3 of these

showed hemolytic streptococci on culture from the mastoid cells at

operation. Missed cases of identification of S. hemolyticus by throat

culture in cases which develop S. hemolyticus complications may arise

from a number of causes. It is desired here only to direct attention to

these discrepancies.

=Pneumonia Following Measles.=—Fifty-six cases of pneumonia following

measles occurred during the period of observation in this group of 867

cases of measles. Of these, 9 were streptococcus pneumonias. This gives

an incidence for streptococcus pneumonias of 1.04 per cent, while that

for all the pneumonia is 6.4 per cent. There were 8 cases of lobar and

48 cases of bronchopneumonia. Seventeen fatal cases occurred giving a

mortality rate of 30.4 per cent for the group. Five of these fatal cases

occurred among the 9 streptococcus pneumonias. The mortality rate for

the streptococcus pneumonia thus was 55.5 per cent; that for the

nonstreptococcus group was 25.5 per cent. All 9 cases of streptococcus

pneumonia developed empyema. In 7 cases it was diagnosed clinically; in

2 at autopsy only. No cases of empyema developed in the group of

nonstreptococcus pneumonias.

TABLE LXIV

COMPLICATIONS DEVELOPING IN 867 CASES OF MEASLES AT CAMP PIKE. DISTRIBUTION

OF COMPLICATIONS BETWEEN 242 “CARRIERS” AND 625 “NONCARRIERS” OF HEMOLYTIC

STREPTOCOCCI FROM SEPTEMBER 15 TO DECEMBER 15, 1918

═════════════╤═════════════════════════════╤══════╤══════════════════════════

NAME OF │ │TOTAL │

COMPLICATION │ NUMBER OCCURRING IN │NUMBER│ PER CENT IN

─────────────┼──────────┬─────────┬────────┼──────┼─────┬──────────┬─────────

„ │ │ │ CASES │ │ │ │

│ │ │WITH IN-│ │ │ │

│ │ │COMPLETE│ │ │ │

│ │ “NON- │ RECORD │ │ │ │ “NON-

│“CARRIERS”│CARRIERS”│ OF │ │ │ HEM. │CARRIERS”

│ OF HEM. │ OF HEM. │ THROAT │ │ ALL │ STREP. │ OF HEM.

│ STREP. │ STREP. │CULTURES│ „ │CASES│“CARRIERS”│ STREP.

─────────────┼──────────┼─────────┼────────┼──────┼─────┼──────────┼─────────

Pneumonia │ 12│ 44│ 0│ 56│ 6.4│ 5.0│ 7.0

Otitis media │ 31│ 11│ 6│ 48│ 5.5│ 12.8│ 1.8

Mastoiditis │ │ │ │ │ │ │

(following │ │ │ │ │ │ │

otitis │ │ │ │ │ │ │

media) │ 15│ 4│ 4│ 23│ 2.6│ 6.2│ 0.6

Local │ │ │ │ │ │ │

meningitis │ │ │ │ │ │ │

(extension │ │ │ │ │ │ │

from │ │ │ │ │ │ │

mastoid) │ 2│ 0│ 0│ 2│ │ │

Frontal │ │ │ │ │ │ │

sinusitis │ 1│ 0│ 0│ 1│ │ │

Ethmoidal │ │ │ │ │ │ │

sinusitis │ 0│ 1│ 0│ 1│ │ │

Suppurative │ │ │ │ │ │ │

arthritis │ 1│ 0│ 0│ 1│ │ │

Cervical │ │ │ │ │ │ │

adenitis │ 1│ 0│ 0│ 1│ │ │

Acute │ │ │ │ │ │ │

bronchitis │ 4│ 2│ 0│ 6│ │ │

Acute │ │ │ │ │ │ │

tonsillitis│ 4│ 1│ 0│ 5│ │ │

Acute │ │ │ │ │ │ │

laryngitis │ │ │ │ │ │ │

and aphonia│ 1│ 0│ 0│ 1│ │ │

Acute │ │ │ │ │ │ │

pleurisy │ 2│ 1│ 0│ 3│ │ │

Erysipelas of│ │ │ │ │ │ │

face │ 0│ 1│ 0│ 1│ │ │

Epidemic │ │ │ │ │ │ │

meningitis │ 0│ 1│ 0│ 1│ │ │

─────────────┴──────────┴─────────┴────────┴──────┴─────┴──────────┴─────────

Note.—The percentages of incidence of pneumonia and otitis media in the

“carrier” and “noncarrier” groups are at direct variance. It would appear

from these findings that streptococci very readily invade the middle ear from

the throat and set up grave disorders. The invasion of the lung from the

throat occurs with less frequency. Hemolytic streptococci perhaps never

initiate the pneumonic processes and can be regarded as more or less

accidental secondary invaders.

The relation of these pneumonias following measles, to the influenza

epidemic has been discussed. The time relations between the onsets of

measles and that of the subsequent pneumonia vary widely. There appears

to be nothing constant in the length of time between the onset of

measles and that of the pneumonia. In 30 of the cases this period is

less than ten days; in the remaining 26 cases, it ranges from ten to

thirty-two days (Chart 4).

In the ward treatment of these cases of pneumonia, they were divided

into three groups according to their clinical characters and according

to the results of throat and sputum cultures.

(_a_) Streptococcus pneumonias 9 cases

(_b_) Pneumonia with hemolytic streptococci in the throat

without symptoms referable to the streptococcus 13 cases

(_c_) Pneumococcus pneumonias not carrying hemolytic

streptococci 34 cases

The streptococcus-free cases were treated in a separate ward. Cases were

admitted to this ward directly from the “clean” measles wards, but only

after a throat culture taken prior to their transfer had been negative

for the hemolytic streptococcus.

The other two groups were treated together in another ward, but in

strictly separate compartments of it. This precaution was carried out on

the assumption that patients with an acute streptococcus pneumonia were

real sources of danger in the ward because of a heightened virulence of

the organism causing the grave symptoms. The pneumonias subsequently

developing hemolytic streptococci in their throats, without their

presence modifying the course of the pneumonia, came to be regarded as

being in the same class with uncomplicated cases of measles carrying

hemolytic streptococci, in so far as their being potential sources of

danger in a ward is concerned.

[Illustration:

Chart 4.—Shows the time interval between the onset of measles and the

onset of the subsequent pneumonia in the 56 cases of pneumonia

following measles at Camp Pike. Each case is represented by one of

the small blocks measured along the ordinate. The onset of measles

in all cases is represented by the line at the extreme left of the

chart. The onset of pneumonia in each case is indicated by the limit

of the block marked off in days to the right of this line.

]

(_a_) =Streptococcus Pneumonias.=—Nine cases of streptococcus pneumonia

developed. Of the 867 cases of measles studied, 242 showed throat

cultures positive for the hemolytic streptococci at some period of their

stay in the hospital. It appears then that 3.7 per cent of the patients

carrying hemolytic streptococci in their throats developed streptococcus

pneumonia. Thirty-seven cases had positive throat cultures when first

observed on admission to the measles wards. It is significant to note

that not a single case of pneumonia of any kind developed among these

cases.

MEASLES PNEUMONIA; STREPTOCOCCUS GROUP

Case 98, O. McN. Onset of measles, Sep. 19; admitted to hospital

Sep. 21; onset of bronchopneumonia, Oct. 21; of empyema, Oct. 23.

Recovered from pneumonia; convalescent in empyema ward.

_Bacteriology._—1. Throat culture for: (_a_) S. hem.: Sep. 21, −;

28, −; Oct. 9, −; 20, −; 23, +; Nov. 2, −; 9, −; 15, −; (_b_) B.

influenzæ: Sep. 21, +; 28, −; Oct. 9, +. 2. Pleural fluid (culture)

S. hem. Oct. 23, +.

Case 141, J. G. G. Autopsy No. 438. Onset of measles, Sep. 28;

admitted to hospital, Oct. 1; onset of bronchopneumonia, Oct. 6; of

otitis media (bilateral), Oct. 12; died, Oct. 18.

_Bacteriology._—1. Throat culture for: (_a_) S. hem., Oct. 2, −; 6,

−; 8, −; (_b_) B. influenzæ, Oct. 2, −; 6, +; 8, +. 2. Autopsy

cultures: Heart blood, negative; left lung, Pneumococcus II

atypical, B. influenzæ and S. viridans; right lung, S. hem. and B.

influenzæ; right bronchus, S. hem. and B. influenzæ.

Case 147, S. W. Autopsy No. 442. Onset of measles, Oct. 1; admitted

to hospital, Oct. 2; onset of bronchopneumonia, Oct. 17, with chill

and rapid development; died, Oct. 18.

_Bacteriology._—1. Throat culture for: (_a_) S. hem., Oct 2, −; 9 −;

15, −; 18, +; (_b_) B. influenzæ, Oct. 2, −; 9, −; 15, −; 18, −. 2.

Autopsy cultures: Heart blood, S. hem.; right main bronchus, S. hem.

and B. influenzæ.

Case 281, T. M. Onset of measles, Oct. 6; admitted to hospital Oct.

9; onset of bronchopneumonia, Oct. 21; of empyema, Oct. 23;

recovered from pneumonia; convalescent in empyema ward.

_Bacteriology._—1. Throat culture for: (_a_) S. hem., Oct. 10, −;

20, −; 24, +; Nov. 2, +; 9, +; 15, +; (_b_) B. influenzæ, Oct. 10,

−; 20, +. 2. Culture from pleural fluid, Oct. 23, S. hem.

Case 285, J. H. Onset of measles, Oct. 4; admitted to hospital, Oct

9; onset of lobar pneumonia, Oct. 29; of empyema, Nov. 9;

convalescent in empyema ward.

_Bacteriology._—1. Throat cultures for: (_a_) S. hem., Oct. 11, −;

20, −; 24, +; 29, −; Nov. 2, −; 9, −; (_b_) B. influenzæ, Oct. 11,

−. 2. Cultures from pleural fluid, Nov. 9 and 13, S. hem.

Case 714, W. H. Onset of measles, Oct. 26; admitted to hospital,

Oct. 28; otitis media, Nov. 8; onset of bronchopneumonia, Nov. 9; of

empyema, Nov. 17; convalescent in pneumonia ward.

_Bacteriology._—1. Throat cultures for: S. hem., Oct. 28, −; Nov. 4,

−; 12, +; 23, +; 30, +; Dec. 7, +; 12, −. 2. Sputum: Nov. 10,

Pneumococcus II atypical, S. hem. and B. influenzæ.

Case 730, W. S. Autopsy No. 491. Onset of measles, Oct. 26; admitted

to hospital, Oct. 29; onset of bronchopneumonia, Nov. 10; of

empyema, Nov. 11; of cervical adenitis, Nov. 5; died, Nov. 15.

_Bacteriology._—1. Throat culture for: S. hem., Oct. 30, −; Nov. 4,

+. 2. Sputum: Nov. 10, S. hem. 3. Pleural fluid: Nov. 11, S. hem.

Autopsy bacteriology: Heart blood, S. hem.; right main bronchus, B.

influenzæ, B. coli; right lung, S. hem. and B. influenzæ; right

pleura, S. hem.; peritoneum, S. hem.

Case 751, P. B. Autopsy No. 492. Entered hospital, Oct. 19; onset of

measles, Oct. 30; of bronchopneumonia, Nov. 5; of right empyema,

Nov. 12; died, Nov. 16.

_Bacteriology._—1. Throat cultures for: S. hem., Nov. 1, −; 4, +;

15, +. 2. Sputum: Nov. 13, B. influenzæ and S. hem. 3. Autopsy

cultures: Heart blood, S. hem.; right lung, S. hem., Pneumococcus

IV, B. influenzæ, B. coli; pericardium, negative; right pleura, S.

hem.; peritoneum, S. hem.

Case 880, B. McN. Autopsy No. 507. Onset of measles, Nov. 30;

entered hospital, Dec. 3; onset of bronchopneumonia, Dec. 11; of

empyema, Dec. 14; died, Dec. 14.

_Bacteriology._—1. Throat cultures for: S. hem., Dec. 3, −; 5, −;

12, +. 2. Cultures from pleural fluid, Dec. 14, S. hem. 3. Autopsy

cultures: Heart blood, S. hem.; right main bronchus, S. hem., B.

influenzæ, staphylococcus (a few); left lung, S. hem.; left pleura,

S. hem.

The average period in the hospital before the development of the

streptococcus pneumonia is about two weeks. Cases 98 and 285 were in the

hospital thirty and twenty days respectively before the onset of

pneumonia. There is a record of from one to four negative throat

cultures on each case before streptococcus was found in the throat. This

enables us to fix the onset of the pneumonia with reference to the

appearance of the streptococcus in the throat.

Case 141 stands alone as representing a class in which S. hemolyticus

was implanted upon a pneumococcus pneumonia during its course. In this

instance two throat cultures on alternate days after the onset of the

pneumonia were negative for hemolytic streptococci. Unfortunately the

last record of a throat culture is for one taken ten days before the

fatal termination of the case, and it can only be stated that the S.

hemolyticus infection was implanted within the last ten days of the

course of the pneumonia, perhaps on or about October 12 when bilateral

otitis media developed.

In Cases 285 and 730 hemolytic streptococci were found in the throats

five and six days respectively before the onset of pneumonia. They

represent the 2 cases of pneumonia which developed in patients isolated

in the streptococcus “carrier” ward. Case 285 is of particular interest

for several reasons. It is the only case of lobar pneumonia in the group

and happens also to be the only case from which B. influenzæ was not

obtained. S. hemolyticus was found only once on throat culture, i.e.,

five days before the onset of the pneumonia. Three throat cultures after

the onset of the pneumonia were negative. The case ran the course of a

lobar pneumonia. Eleven days after the onset (November 9) a small amount

of pleural fluid was diagnosed. Aspirated fluid on this date and again

four days later showed many streptococci in smears and pure cultures of

S. hemolyticus.

The remaining 6 cases belong to a group in which hemolytic streptococci

were first identified in the throats after the cases had been reported

to the laboratory as pneumonia suspects to be examined by culture before

transfer from the measles ward. In all these cases the culture taken at

this time was positive while all cultures taken before were negative. In

some cases, _e. g._, Cases 98, 147, and 281, throat cultures taken only

one or two days before the onset of the pneumonia were negative. In

these cases the onset of the pneumonia and the appearance of the

streptococcus in the throats appear to be simultaneous.

It should be noted that the period between the appearance of the

hemolytic streptococci in the throat and the development of the

pneumonia is very short in all cases. In this small group of cases S.

hemolyticus infection which has complicated pneumonia has been acquired

at or near the time of onset of the pneumonia.

(_b_) =Pneumonia with Hemolytic Streptococci in the Throat without

Symptoms Referable to the Streptococcus.=—Thirteen cases of pneumonia

associated with measles developed into S. hemolyticus “carriers” without

having the course of the disease affected by the presence of the

organism in the throat. Cases 705, 872, and 188 are of interest in that

hemolytic streptococci were identified in the throats from one to six

days prior to the onset of the pneumonia. In spite of their presence,

the symptoms, course and outcome of the pneumonia were apparently

unaffected. One of these cases (Case 872) died. Autopsy showed lobar

pneumonia with no signs of invasion of the lung by hemolytic

streptococci. Cultures at autopsy showed that pneumonia was due to a

pneumococcus, Type II atypical. A few hemolytic streptococci were found

in culture from the right main bronchus.

Of the remaining 10 cases 1 developed S. hemolyticus in a throat culture

at the end of the first week of the pneumonia; 3 during the second week;

1 during the third week, and 5 further along in the convalescent period.

In 8 cases hemolytic streptococci appeared in the throat, at a time when

invasion of the lower respiratory tract by the streptococcus might be

expected, and yet none of them developed evidence of streptococcus

pneumonia. The 9 cases with hemolytic streptococci appearing late in

convalescence are not of particular interest, since the dangers of lower

respiratory invasion are much reduced after the acute stage of the

pneumonia has passed. Three of these cases (Cases 678, 725 and 398) did

however develop ear complications directly referable to the

streptococcus invasion of the throat. Two of them terminated in

mastoiditis with operation. These cases emphasize the greater tendency

of S. hemolyticus to invade the middle ear rather than the lung.

In 3 fatal cases of pneumococcus pneumonia in which during life no

hemolytic streptococci were found by throat culture, a few hemolytic

streptococci were found at autopsy in culture from the main bronchi,

along with predominating growths of pneumococci and B. influenzæ. In 2

instances there was frank lobar pneumonia and in the third

bronchopneumonia; there was no evidence to show that hemolytic

streptococci had any relation to the pneumonia which was found.

MEASLES PNEUMONIAS; GROUP CARRYING HEMOLYTIC STREPTOCOCCI

Case 705. Onset of measles, Oct. 25; admitted to hospital, Oct. 27;

onset of bronchopneumonia, Nov. 10; acute pleurisy, Nov. 16;

convalescent in pneumonia ward.

_Bacteriology._—1. Throat cultures for: S. hem., Oct. 27, −; Nov. 4,

−; 11, +; 15, +; 23, −; 30, −; Dec. 7, −; 12, −. 2. Sputum: Nov. 10,

Pneumococcus II atypical, S. hem. and B. influenzæ.

Case 872. Autopsy No. 508. Onset of measles, Nov. 29; admitted to

hospital, Nov. 30; onset of lobar pneumonia, Dec. 10; died, Dec. 14.

_Bacteriology._—1. Throat cultures for: S. hem., Nov. 30, −; Dec. 5,

+; 10, +; 12, +; 14, +. 2. Autopsy culture: Heart blood,

Pneumococcus II atypical; right main bronchus, Pneumococcus II

atypical, B. influenzæ, S. hem. (a few); left lung, Pneumococcus II

atypical; left pleura, Pneumococcus II atypical.

Case 188. Onset of measles, Oct. 3; admitted to hospital, Oct. 4;

onset of bronchopneumonia, Oct. 14; recovered and discharged from

hospital, Nov. 24.

_Bacteriology._—1. Throat cultures for: (a) S. hem., Oct. 5, −; 8,

+; 12, +; 19, +; 20, +; 27, −; Nov. 2, −; 9, +; 15, −; (b) B.

influenzæ, Oct. 5, −; 8, −; 12, +; 19, +.

Case 678. Onset of measles, Oct. 23; admitted to hospital, Oct. 25;

onset of bronchopneumonia, Nov. 2; of otitis media, Nov. 9; of

mastoiditis, Nov. 13; mastoid operation, Nov. 20; still under

treatment.

_Bacteriology._—1. Throat cultures for: S. hem., Oct. 25, −; Nov. 4,

−; 5, −; 12, +. 2. Sputum: Nov. 3, Pneumococcus Type IV, and B.

influenzæ. 3. Culture from mastoid bone at operation, Nov. 20, S.

hem.

Case 389. Admitted to hospital, Oct. 2, with diagnosis of influenza;

onset of bronchopneumonia, Oct. 7; onset of measles, Oct. 13;

phlebitis (right leg), Oct. 22; otitis media, Oct. 31; recovered.

_Bacteriology._—1. Throat cultures for: (a) S. hem., Oct. 16 −; 20,

−; 27, +; Nov. 2, +; 9, +; 15, −; 23, −; 30, −; Dec. 7, −; 12, −;

(b) B. influenzæ, Oct. 16, −.

Case 725. Onset of measles, Oct. 18; one week in measles barracks;

admitted to hospital, Oct. 27; onset of lobar pneumonia, Oct. 23;

otitis media, Nov. 7; mastoid operation, Nov. 20; still under

treatment.

_Bacteriology._—1. Throat cultures for: (_a_) S. hem., Oct. 29, −;

Nov. 1, −; 5, −; 12, +; (_b_) B. influenzæ, Oct. 29, +. 2. Sputum:

Nov. 2, Pneumococcus II atypical. B. influenzæ. 3. Culture from

mastoid at operation, Nov. 20, S. hem.

(_c_) =Pneumococcus Pneumonias not Carrying Hemolytic

Streptococci.=—Thirty-four cases of pneumonia following measles went

through their entire course in the hospital with no throat culture

positive for hemolytic streptococci. In some of these cases there are

records of twelve negative throat cultures. Eleven fatal cases occurred

in this group. Autopsy findings and bacteriology showed in each instance

that S. hemolyticus was not the cause of the pneumonia.

=Measles During the Course of Pneumonia.=—Eleven cases of pneumonia

which developed measles during the course of the pneumonia came under

observation. Hemolytic streptococci appeared in the throats of 3 of

these patients during convalescence, but there was no evidence that it

invaded the lung. In one fatal case autopsy showed that there was no

streptococcus pneumonia; pneumonia followed influenza and the onset of

measles occurred three days after the onset of bronchopneumonia.

=Bacteriology of Pneumonia Following Measles.=—When observations made

during life are combined with the results of postmortem cultures, the

bacteriology of 35 of the 56 cases is available and is as follows:

Pneumococcus Type II atypical in 36 per cent, Type IV in 22.9 per cent,

Type I in 2.8 per cent, Type III in 2.8 per cent, hemolytic streptococci

in 22.4 per cent, and B. influenzæ in 88.6 per cent of these cases.

=Otitis Media and Mastoiditis Complicating Measles.=—The occurrence of

otitis media and mastoiditis complicating measles in patients harboring

hemolytic streptococci in their throats has already been presented

(Table LXIV). The bacteriology of these complications was not studied by

this commission. The records of the base hospital laboratory at Camp

Pike contain reports of twenty-nine cultures made at operation from pus

in the middle ear and the mastoid bone. Hemolytic streptococci were

found in 22 of these cases. Throat cultures were in accord with these

positive findings in all except a few instances. The throat culture

serves as a fairly reliable index of the bacterial nature of these

complications. By combining our records of throat cultures with the

results of the cultures from the lesions, hemolytic streptococci were

obtained from 37 of the 48 cases of otitis media. In 23 cases of

mastoiditis following the otitis media, hemolytic streptococci were

demonstrated in all except 2. It is evident that the great majority of

these complications were due to hemolytic streptococci.

The relation between the appearance of hemolytic streptococci in the

throat and the onset of the otitis is recorded in all except 4 of the 31

instances of otitis media occurring in patients with throat cultures

positive for hemolytic streptococci. These four patients had positive

throat cultures when first observed and represent the only patients who

carried hemolytic streptococci when admitted to measles wards and

developed complications.

The first of these patients had been under treatment in an otologic ward

during a month before measles developed. Measles caused a recurrence of

disease of the ear with double mastoiditis requiring bilateral

operation. Two other patients had been in the hospital ten and eleven

days respectively before they were admitted to the measles ward; on

admission to the ward otitis media was present in one patient and in the

other it developed six days later. The fourth patient was admitted to

the measles wards directly from the camp, and culture from the throat on

the day of admission showed the presence of S. hemolyticus. Two weeks

later at the time of onset of otitis media, culture from the throat

contained no hemolytic streptococci. Repeated cultures during the next

three weeks were negative. No complications of otitis media developed

and no direct cultures from the ear are recorded.

[Illustration:

Chart 5.—Shows the time relation between the identification of

hemolytic streptococci in the throats and the development of otitis

media in 27 cases shown to be due to hemolytic streptococci. The

onset of otitis media is represented by the ordinate marked ○. The

number of days before or after the onset of the otitis, within which

the throat culture which proved positive for hemolytic streptococci

was taken, is marked off along abscissæ to the left and right of

ordinate ○ respectively. On the curve plotted these symbols are

used: A circle represents a throat culture positive for hemolytic

streptococci in a case of otitis media without extension to mastoid.

The plus sign represents a throat culture positive for hemolytic

streptococci in a case of otitis media with mastoiditis and

osteitis.

]

In this series of cases (Chart 5) the appearance of S. hemolyticus in

the throat and the onset of otitis media are very closely associated in

those patients in whom further extensions of the streptococcus infection

occurred. In instances in which appearance of streptococci and of otitis

media are separated by an interval of more than seven days, no further

extension occurred. In 8 cases in which this interval is seven days or

less there has been no further extension of the infection.

The Dissemination of Hemolytic Streptococci in Wards

Beginning October 24 cultures for the identification of carriers of

hemolytic streptococci were made from all patients in a ward and

repeated at intervals of one week. Prior to this time individual

patients had been examined at intervals of one week, so that an entire

ward was never studied on any particular day. This system did not

identify and remove all “carriers” in a ward at a given time and was

abandoned because it failed to show the conditions present.

Investigation of wards as units proved much more satisfactory.

The studies made in four of the double wards used for the care of

patients with measles are presented in Table LXV. During the time of

this study hemolytic streptococci were more prevalent than at an earlier

period.

Cultures from the throats of all patients entering these wards were

negative for S. hemolyticus on admission. The table showing the

incidence of “carriers” of hemolytic streptococci each week in these

wards demonstrates:

1. The separation of “carriers” and “noncarriers” by throat culture made

on admission does not prevent the increase of streptococcus “carriers”

in wards.

2. Removal of all “carriers” found by cultures on admission and at

weekly intervals is inadequate.

TABLE LXV

WARD CONDITIONS WITH REFERENCE TO HEMOLYTIC STREPTOCOCCUS INFECTION

═══════╤════════╤════════╤═════════╤═════════════╤═════════════════════

DATE OF│ NO. │ NO. │PER CENT │COMPLICATIONS│

CULTURE│PATIENTS│POSITIVE│POSITIVE │ ASSOCIATED │

│CULTURED│ HEM. │ HEM. │ WITH HEM. │ REMARKS

│ │ STREP. │ STREP. │ STREP. WITH │

│ │ │ │ DATES OF │

│ │ │ │ ONSET │

───────┼────────┼────────┼─────────┼─────────────┼─────────────────────

Ward 57│ │ │ │ │

11–3 │35 │1 │2.8 │ │

11–10 │13 │2 │15.5 │None │

11–17 │16 │6 │37.5 │ │

Ward 58│ │ │ │ │Wards 57 and 58

│ │ │ │ │ served by same ward

│ │ │ │ │ staff.

11–3 │38 │7 │18.4 │Otitis media:│ „

11–10 │11 │4 │36.4 │11–8 1 case │Members of staff

│ │ │ │ │ cultured on 11–5,

│ │ │ │ │ 11–12 and 11–19. No

│ │ │ │ │ positives

11–17 │6 │2 │33.0 │11–7 1 case │ „

Ward 49│ │ │ │ │

│ │ │ │Otitis media:│

10–25 │37 │7 │18.9 │10–25 2 cases│

11–1 │31 │3 │9.7 │10–26 1 case │

11–8 │35 │9 │25.7 │10–28 1 case │

11–15 │32 │18 │56.3 │11–15 1 case │

11–22 │16 │7 │43.8 │11–18 1 case │

│ │ │ │11–27 1 case │

Ward 50│ │ │ │ │Wards 49 and 50

│ │ │ │ │ served by same ward

│ │ │ │ │ staff.

10–25 │29 │2 │3.4 │Otitis media:│ „

11–1 │43 │2 │4.6 │11–8 1 case │Ward staff cultured:

│ │ │ │ │ 11–5 1 positive

│ │ │ │ │ 11–12 1 positive

│ │ │ │ │ 11–26 2 positives

11–8 │32 │3 │9.4 │11–13 1 case │ „

11–15 │20 │11 │55.0 │11–22 1 case │ „

11–22 │11 │0 │0.0 │ │ „

Ward 41│ │ │ │ │Case of pneumonia

│ │ │ │ │ developing on 11–9

│ │ │ │ │ was transferred to

│ │ │ │ │ the “clean”

│ │ │ │ │ pneumonia ward

│ │ │ │ │ without a throat

│ │ │ │ │ culture to warrant

│ │ │ │ │ its transfer; last

│ │ │ │ │ culture 11–4

│ │ │ │ │ negative; culture

│ │ │ │ │ 11–12 in pneumonia

│ │ │ │ │ ward positive

10–28 │45 │4 │8.9 │Streptococcus│ „

│ │ │ │pneumonia: │

11–4 │34 │9 │26.5 │(11–9 1 case)│ „

11–11 │12 │8 │66.6 │11–10 1 case │ „

Ward closed—No patients. │Otitis media:│ „

11–21 │13 │0 │0.0 │10–29 1 case │ „

11–28 │8 │4 │50.0 │11–4 1 case │ „

12–5 │12 │4 │33.3 │11–5 1 case │ „

12–12 │4 │3 │75.0 │11–11 1 case │ „

│ │ │ │11–27 1 case │ „

│ │ │ │12–3 1 case │ „

Ward 42│ │ │ │ │Wards 41 and 42

│ │ │ │ │ served by same ward

│ │ │ │ │ staff.

│ │ │ │Streptococcus│ „

│ │ │ │pneumonia: │

10–28 │32 │0 │0 │11–10 1 case │ „

11–4 │43 │7 │16.3 │12–11 1 case │ „

Ward closed—No patients. │Otitis media:│Ward staff cultured:

│ │ 11–5 2 positive

│ │ 11–12 2 positive

│ │ 11–26 2 positive

│ │ 12–2 1 positive

10–21 │16 │4 │25.0 │10–29 1 case │ „

11–28 │12 │1 │12.5 │12–3 1 case │ „

12–5 │20 │10 │50.0 │12–6 1 case │ „

12–12 │14 │7 │50.0 │ │ „

Ward 59│ │ │ │ │The 3 cases of

│ │ │ │ │ streptococcus

│ │ │ │ │ pneumonia acquired

│ │ │ │ │ S. hemolyticus

│ │ │ │ │ infection while

│ │ │ │ │ patients in the 16

│ │ │ │ │ bed south section

│ │ │ │ │ of this ward

│ │ │ │Streptococcus│ „

│ │ │ │pneumonia: │

10–24 │37 │6 │16.2 │10–17 1 case │ „

10–31 │27 │5 │18.5 │10–21 1 case │ „

11–7 │9 │3 │33.3 │10–29 1 case │Case developing 10–29

│ │ │ │ │ was removed from

│ │ │ │ │ section a few days

│ │ │ │ │ before onset of

│ │ │ │ │ pneumonia

11–12 │7 │1 │14.3 │Otitis media:│ „

│ │ │ │11–1 1 case │ „

Ward 60│ │ │ │ │Wards 59 and 60

│ │ │ │ │ served by same ward

│ │ │ │ │ staff.

│ │ │ │Streptococcus│ „

│ │ │ │pneumonia: │

10–24 │22 │1 │4.5 │10–21 1 case │Ward staff cultured:

│ │ │ │ │ 11–5 0 positive

│ │ │ │ │ 11–12 1 positive

│ │ │ │ │ 11–19 0 positive

10–31 │17 │2 │11.7 │Otitis media:│ „

11–7 │8 │1 │12.5 │10–31 1 case │ „

11–12 │6 │1 │16.6 │ │ „

───────┴────────┴────────┴─────────┴─────────────┴─────────────────────

When the streptococcus complications are traced back to the wards in

which the streptococcus infection of the throat was acquired, it is

found that with the exception of Case 141 (already cited) all the

streptococcus pneumonias arose from two double wards. Wards 41 and 42

furnished 4 cases at times when streptococcus was rampant in them and 3

of these cases arose within a period of a few days. Wards 59 and 60

furnished 4 cases, very closely associated. In 3 cases the streptococcus

infection was acquired in a section of Ward 59 containing 16 beds. These

patients were in beds, of which the positions are represented by numbers

2, 5, and 7, along one side of the ward. The fourth instance of

pneumonia appeared at the same time in Ward 60, which was attended by

the same ward personnel, but no other connection can be established

between this case and the other three.

The otitis media appeared in patients scattered throughout those wards

for measles in which the weekly incidence of “carriers” was rising

rapidly. This relation is illustrated by Wards 58, 50, and 41. The same

observation applies to streptococcus pneumonia arising in Wards 41 and

42. In Ward 41 the weekly percentage of carriers are October 28, 8.9,

November 4, 26.5 and November 11, 66.6. On November 9 and 10 the first 2

cases of streptococcus pneumonia arising from this ward developed. At

the same time, November 10, a third case appeared in another part of

this same ward unit (Ward 42) where the spread of hemolytic streptococci

had been very active. These observations suggest that hemolytic

streptococci may build up its virulence as the result of rapid

dissemination to such a degree that it is capable of causing grave

complications.

The relation of complications to “carriers” in Wards 59 and 60 is

different from that in the wards just cited. Wards 59 and 60 were opened

on October 9 and before October 17; when the first case of fulminating

streptococcus pneumonia occurred, only three “carriers” had been found

in them. From October 17 to 24 when the record in Table LXV begins eight

“carriers” were removed. The appearance of a case of severe

streptococcus pneumonia in an unusually clean ward was followed by the

rapid development of “carriers,” and the appearance within twelve days

of 3 other cases of streptococcus pneumonia, 2 of which were in beds

close to the first case. This sequence suggests focal dissemination of a

streptococcus from a case in which it had suddenly assumed high

virulence.

An outbreak of infection with S. hemolyticus was recognized on November

12 in a measles-pneumonia ward which had been opened for several weeks

and had continued free from streptococcus. In three patients hemolytic

streptococci were found by throat cultures. Inquiry revealed that a

nurse in this ward, recognized as a streptococcus “carrier” the week

before, had been retained on duty. Two patients well advanced in the

course of their pneumonias, had acquired S. hemolyticus demonstrated by

throat examination. Both patients developed otitis media with mastoid

extension requiring operations. Cultures from both at operation showed

hemolytic streptococci.

The third patient, with acute pneumonia, had been sent into the ward on

November 11 from Ward 42, which at the time was a highly infected ward;

no culture of the throat was made before transfer. This patient

developed streptococcus pneumonia with empyema requiring subsequent

operation.

=Discussion.=—At Camp Funston, where the prevalence of S. hemolyticus in

the measles wards did not rise above that among normal men in the camp

at large, 112 consecutive cases of measles were treated without a single

complication due to hemolytic streptococci.

At Camp Pike, the investigation began at the onset of a small epidemic

of measles at a time when hemolytic streptococci were an almost

negligible factor. The epidemic of measles was followed throughout its

course; and, with the passing of the epidemic, there was an increase in

the prevalence of hemolytic streptococci which assumed alarming

importance in the production of complications.

The epidemic of measles was in part superimposed upon the epidemic of

influenza, so that deductions concerning complications strictly due to

measles became impossible. It is evident that influenza played a

considerable part in producing the complications of measles at Camp

Pike.

The dissemination of hemolytic streptococci through measles wards was

controlled only in part by the methods used. This partial control may

have served to limit the incidence of streptococcus pneumonia, nine

instances occurring among 867 cases of measles.

In the ward treatment of measles effort should be directed to prevent

the exposure of patients free from hemolytic streptococci to S.

hemolyticus “carriers.” By this means the rate of development of S.

hemolyticus “carriers” may be reduced.

Measures which should be adopted are as follows:

1. Adequate wards should be prepared in advance for the treatment of

measles. The rather gradual onset of epidemics of measles makes this

provision possible.

2. The separation of S. hemolyticus “carriers” from other patients

should be enforced. Observation wards, where strict technic to prevent

transfer of infection is practiced and where throat cultures are made on

admission, are essential. Those wards should be promptly evacuated to

wards for the care of S. hemolytic “carriers” on the one hand and for

“noncarriers” on the other. As far as possible patients should be

admitted to a ward until it is filled and then another ward should

receive consecutive cases in the same manner. It is desirable to have

all cases in each treatment ward in the same stage of the disease. With

this system of ward rotation convalescent wards are necessary, so that

cases requiring a period of hospitalization longer than the average may

be segregated, thus rendering treatment wards available for another levy

of acute cases.

3. Strict ward technic elaborated to prevent transfer of bacterial

infection from one patient to another must be employed.

4. Throat culture for identification of “carriers” is laborious but

essential. An accurate method for identifying and reporting “carriers”

as speedily as possible must be employed. A competent bacteriologist is

essential. A twenty-four hour interval between culture and its report is

desirable. The following scheme is recommended:

(_a_) A culture from the throat made on admission to the observation

ward (first day in hospital).

(_b_) A culture made on the first day in the treatment ward (third day

in hospital).

(_c_) A culture made one week later (tenth day in hospital).

If the ward incidence of hemolytic streptococci reaches 10 per cent,

especially in a filled ward, the cultures should be repeated on the

thirteenth day in the hospital. If the incidence of “carriers” of

hemolytic streptococci increase rapidly, cultures on alternate days

should be made so that “carriers” may be removed from the ward. Wherever

possible, culturing of the treatment wards as units should be practiced.

5. Patients developing acute symptoms in any way suggestive of infection

with S. hemolyticus should be immediately isolated; culture from the

throat should be made at once and final disposal of the patient should

depend upon its result.

Carriers of Hemolytic Streptococci

During the winter of 1917–18, with the establishment of the army camps,

it very soon became evident that in many of the serious and fatal

complications of measles and other respiratory diseases, hemolytic

streptococci were playing a very important rôle. The epidemic prevalence

of hemolytic streptococci among hospital cases, and later among men on

duty in the camps, was established by bacteriologic studies. Prior to

this time in civil life, hemolytic streptococci under epidemic

conditions had been studied in milk-borne epidemics of septic sore

throat, such as are reported from Chicago in 1911–13[92]; from Boston in

1911[93]; and from Baltimore in 1911–12[94]. Contact air-borne infection

has not been emphasized in considering the dissemination of hemolytic

streptococci. Smillie[95] reports a few cases of hemolytic streptococcus

throat infections which he attributes to contact infection. Conditions

within the army camps were such as to suggest the dissemination of

hemolytic streptococci by contact air-borne infection. Some knowledge of

the percentage of individuals showing positive throat cultures became

desirable at the very beginning of studies of contact dissemination of

hemolytic streptococci.

Smillie found that only one of 100 normal throats harbored the Beta

hemolytic streptococci of Smith and Brown. Levy and Alexander[96] report

the presence of hemolytic streptococci in 83.2 per cent of healthy men

at Camp Taylor, and hemolytic organisms (not definitely identified as

streptococci) in 14.8 per cent of recruits arriving at Camp Taylor.

Irons and Marine[97] found hemolytic streptococci among 70 per cent of

healthy men at Camp Custer.

Among measles patients on admission to the hospital at Fort Sam Houston,

Cole and MacCallum[98] report 11.4 per cent and Cummings, Spruit and

Lynch,[99] 35 per cent of throat cultures positive for hemolytic

streptococci. At Camp Taylor, Levy and Alexander report 77.1 per cent

positive among 388 cases of measles on admission to the hospital.

The spread of hemolytic streptococci in measles wards was shown by Cole

and MacCallum when on admission 11.4 per cent of cases had positive

throat cultures, 38.6 per cent after from three to five days, and 56.8

per cent after from eight to sixteen days in the ward. In our study of

hemolytic streptococci with measles at Camp Funston, 2.6 per cent of the

cases had positive throat cultures on admission, 12.8 per cent after

three to ten days, and 24.1 per cent after eight to twenty-three days in

the hospital. In a similar study at Camp Pike we found 1.7 per cent

positive on admission; 10.9 per cent after one week; 22.8 per cent after

two weeks; 26.2 per cent after three weeks; and, 33.1 per cent after

four weeks in the hospital.

=Hemolytic Streptococci in the Throats of Normal Men.=—The percentage of

normal individuals harboring hemolytic streptococci in their throats was

investigated in three distinct classes of men, classified according to

the degree of exposure to contact infection.

The first group includes men largely from country districts, cultured

within an hour after being assembled by their local draft board. The

laboratory car “Lister” was sent to Hot Springs, Ark. to meet the

November draft of men to be sent to Camp Pike. These men were returned

to their homes when the armistice was signed, so that there was no

opportunity to study them after they had lived under camp conditions.

The second group includes men on duty in Camps Funston and Pike. These

men, while largely from country districts, had been living crowded

together in the camp for a period varying from a few weeks to several

months.

The third group includes normal men resident in the base hospitals at

Ft. Riley and Camp Pike. This group includes at Camp Pike the medical

personnel of the measles and measles pneumonia wards and represents

individuals most exposed to contact infection with hemolytic

streptococci. On the other hand, the group includes doctors, nurses and

seasoned medical detachment men who are perhaps less susceptible to

respiratory infections than are raw recruits.

The results of studies of these groups are presented in Tables LXVI and

LXVII.

TABLE LXVI

HEMOLYTIC STREPTOCOCCI IN THROATS OF NORMAL MEN NOT RESIDENT IN THE

BASE HOSPITAL

═════════════╤═══════╤════════╤════════╤═══════════════════════════════

PLACE OF │NO. OF │ NO. │PER CENT│ REMARKS

STUDY │ CASES │POSITIVE│POSITIVE│

DATE │ │FOR HEM.│FOR HEM.│

│ │ STREP. │ STREP. │

─────────────┼───────┼────────┼────────┼───────────────────────────────

Camp Funston,│ 274│ 60│ 21.9│Men on duty in camp including

Kan., │ │ │ │ 201 white and 73 colored; in

Aug., 1918.│ │ │ │ great part newly drafted men

Camp Pike, │ 337│ 25│ 7.4│Largely white men on duty in

Ark., │ │ │ │ camp

Nov. 5 to │ │ │ │

Dec. 10, │ │ │ │

1918 │ │ │ │

Hot Springs, │[100]64│ 0│ 0.0│Men from country districts,

Ark., │ │ │ │ assembled by the local draft

Nov. 12, │ │ │ │ board

1918 │ │ │ │

─────────────┴───────┴────────┴────────┴───────────────────────────────

TABLE LXVII

HEMOLYTIC STREPTOCOCCI IN THROATS OF NORMAL MEN RESIDENT IN THE BASE

HOSPITAL

PLACE OF │NO. OF │ NO. │PER CENT│ REMARKS

STUDY │ CASES │POSITIVE│POSITIVE│

DATE │ │FOR HEM.│FOR HEM.│

│ │ STREP. │ STREP. │

Ft. Riley, │ 24│ 7│ 29.2│14 convalescent patients in a

Kan., │ │ │ │ surgical ward; 10 laboratory

Aug., 1918 │ │ │ │ workers

Camp Pike, │ 153│ 22│[101]7.5│Personnel of measles wards

Ark., │ │ │ │

Sept. 10 to│ │ │ │

Nov. 30, │ │ │ │

1918. │ │ │ │

The group of men studied at Hot Springs represents individuals among

whom there was little chance for contact dissemination of hemolytic

streptococci. It is a control series of men from outlying districts

examined before their throat bacteriology has been complicated by the

interchange of mouth organisms which occurs when a group of men are

crowded into close quarters. The entire absence of hemolytic

streptococci by the throat culture method is noteworthy. By multiplying

the chances of identifying hemolytic streptococci by making parallel

cultures from the saliva, and from the peritoneal exudates of mice

inoculated with saliva, hemolytic streptococci were found, in small

numbers, in 3 instances. The findings in this group were only three

throats lightly infected with hemolytic streptococci. They are in direct

contrast with the findings among individuals living in camps under

crowded conditions and are in accord with the findings among recruits

arriving in camp as recorded by Levy and Alexander.

In the second group, men living for a time in camp, the findings at Camp

Funston and at Camp Pike show rather striking differences. The lower

percentage incidence at Camp Pike is the more remarkable since the

studies were made soon after the influenza epidemic had swept the camp

and made necessary the hospitalization of about 20 to 25 per cent of the

camp population.

In the third group, namely, individuals resident in the hospital,

percentage rates at Camp Funston are slightly higher than for men

resident in camp. This difference disappears for the entire group at

Camp Pike if we consider a single throat culture, as we must for the

sake of comparison. The majority of these individuals at Camp Pike

served in measles wards from which patients carrying hemolytic

streptococci were removed at weekly intervals. Seven and one-half per

cent of the ward personnel were positives when first cultured. An

additional 7.5 per cent acquired the streptococcus while under

observation.

=Duration of the “Carrier” State.=—Unfortunately there are very few

observations with regard to the duration of the “carrier” state which

can be determined only by repeated cultures at short intervals. We have

made no observations of the duration of the “carrier” state in healthy

men. Two hundred and forty-two individuals carrying hemolytic

streptococci were identified in the ward treatment of measles. All

except 37 of these cases were “noncarriers” when first observed. The

remaining 205 include 166 contact “carriers” and 39 patients with acute

symptoms of infection by hemolytic streptococci.

The complete record of throat cultures on these cases is presented in

Table LXVIII.

=Group I= includes 37 cases positive for hemolytic streptococci on

admission.

(_a_) Twenty-two of these remained positive throughout the period of

observation. Four patients became negative after one or two weeks and

later showed positive findings, leaving the hospital as positives. These

are classified as “irregular.” The results of culture were as follows:

Cultured once only, 7; positive after one week, 7; positive after two

weeks, 6; positive after three weeks, 2; irregular, 4.

TABLE LXVIII

RESULTS OF THROAT CULTURES IN 242 HOSPITAL PATIENTS IDENTIFIED AS “CARRIERS” OF

HEMOLYTIC STREPTOCOCCI; CULTURES TAKEN AT WEEKLY INTERVALS

═════╤════╤════╤════╤════╤════╤════╤════╤════╤════╤════╤════╤════╤═══════╤═════

GROUP│1st │2nd │3rd │4th │5th │6th │7th │8th │9th │10th│11th│12th│No. of │ No.

│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Cul-│Contact│with

│ture│ture│ture│ture│ture│ture│ture│ture│ture│ture│ture│ture│ “Car- │Acute

│ │ │ │ │ │ │ │ │ │ │ │ │riers.”│Hem.

│ │ │ │ │ │ │ │ │ │ │ │ │ │Strep.

│ │ │ │ │ │ │ │ │ │ │ │ │ │Com-

│ │ │ │ │ │ │ │ │ │ │ │ │ │pli-

│ │ │ │ │ │ │ │ │ │ │ │ │ │ ca-

│ │ │ │ │ │ │ │ │ │ │ │ │ │tions

─────┼────┼────┴────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼───────┼─────

=I=│=37=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

─────┼────┼────┬────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼───────┼─────

│ +│ │ │ │ │ │ │ │ │ │ │ │ 7│

─────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼───────┼─────

│ +│ + │ │ │ │ │ │ │ │ │ │ │ 7│

│ +│ + │ + │ │ │ │ │ │ │ │ │ │ 6│

│ +│ + │ + │ + │ │ │ │ │ │ │ │ │ 2│

│ +│ − │ │ │ │ │ │ │ │ │ │ │ 8│

│ +│ − │ − │ │ │ │ │ │ │ │ │ │ 1│

│ +│ − │ − │ − │ − │ │ │ │ │ │ │ │ 1│

│ +│ + │ − │ │ │ │ │ │ │ │ │ │ 1│

│ +│ − │ + │ │ │ │ │ │ │ │ │ │ 2│

│ +│ − │ − │ − │ − │ + │ + │ + │ │ │ │ │ 1│

│ +│ + │ − │ − │ + │ + │ + │ │ │ │ │ │ 1│

=II=│=67=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ + │ │ │ │ │ │ │ │ │ │ │ 26│ 3

│ −│ + │ + │ │ │ │ │ │ │ │ │ │ 12│ 5

│ −│ + │ + │ + │ │ │ │ │ │ │ │ │ 2│ 2

│ −│ + │ − │ │ │ │ │ │ │ │ │ │ 9│ 1

│ −│ + │ − │ − │ │ │ │ │ │ │ │ │ 0│ 1

│ −│ + │ + │ − │ │ │ │ │ │ │ │ │ 2│ 1

│ −│ + │ + │ + │ + │ − │ − │ + │ − │ │ │ │ 1│

│ −│ + │ − │ + │ │ │ │ │ │ │ │ │ 2│

=III=│=74=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ − │ + │ │ │ │ │ │ │ │ │ │ 38│ 5

│ −│ − │ + │ + │ │ │ │ │ │ │ │ │ 5│ 3

│ −│ − │ + │ + │ + │ │ │ │ │ │ │ │ 4│ 1

│ −│ − │ + │ + │ + │ + │ │ │ │ │ │ │ 0│ 2

│ −│ − │ + │ − │ − │ − │ │ │ │ │ │ │ 0│ 1

│ −│ − │ + │ − │ │ │ │ │ │ │ │ │ 4│

│ −│ − │ + │ + │ − │ − │ − │ − │ │ │ │ │ 1│

│ −│ − │ + │ + │ − │ │ │ │ │ │ │ │ 0│ 2

│ −│ − │ + │ + │ − │ − │ − │ │ │ │ │ │ 1│

│ −│ − │ + │ + │ + │ + │ − │ │ │ │ │ │ 0│ 1

│ −│ − │ + │ − │ + │ │ │ │ │ │ │ │ 1│

│ −│ − │ + │ − │ + │ + │ │ │ │ │ │ │ 2│

│ −│ − │ + │ − │ + │ + │ + │ │ │ │ │ │ 1│

│ −│ − │ + │ − │ − │ + │ + │ │ │ │ │ │ 1│

│ −│ − │ + │ + │ + │ − │ − │ + │ │ │ │ │ 1│

=IV=│=34=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ − │ − │ + │ │ │ │ │ │ │ │ │ 12│ 4

│ −│ − │ − │ + │ + │ │ │ │ │ │ │ │ 5│

│ −│ − │ − │ + │ + │ + │ │ │ │ │ │ │ 4│

│ −│ − │ − │ + │ − │ │ │ │ │ │ │ │ 3│ 1

│ −│ − │ − │ + │ − │ − │ │ │ │ │ │ │ 1│

│ −│ − │ − │ + │ + │ − │ │ │ │ │ │ │ 1│

│ −│ − │ − │ + │ + │ + │ − │ │ │ │ │ │ 1│

│ −│ − │ − │ + │ − │ − │ + │ + │ │ │ │ │ 1│

│ −│ − │ − │ + │ + │ − │ − │ − │ − │ − │ │ │ 0│ 1

=V=│=16=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ − │ − │ − │ + │ │ │ │ │ │ │ │ 1│ 1

│ −│ − │ − │ − │ + │ + │ │ │ │ │ │ │ 1│ 1

│ −│ − │ − │ − │ + │ − │ │ │ │ │ │ │ 3│ 1

│ −│ − │ − │ − │ + │ − │ − │ │ − │ │ │ │ 0│ 2

│ −│ − │ − │ − │ + │ − │ − │ − │ − │ − │ │ │ 1│

│ −│ − │ − │ − │ + │ + │ − │ │ │ │ │ │ 1│

│ −│ − │ − │ − │ + │ − │ + │ │ │ │ │ │ 2│

│ −│ − │ − │ − │ + │ + │ − │ │ + │ │ │ │ 1│

│ −│ − │ − │ − │ + │ + │ − │ − │ − │ + │ │ │ 1│

=VI=│ =7=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ − │ − │ − │ − │ + │ │ │ │ │ │ │ 1│

│ −│ − │ − │ − │ − │ + │ + │ │ │ │ │ │ 2│

│ −│ − │ − │ − │ − │ + │ − │ │ │ │ │ │ 3│

│ −│ − │ − │ − │ − │ + │ − │ − │ │ │ │ │ 1│

=VII=│ =4=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

│ −│ − │ − │ − │ − │ − │ + │ │ │ │ │ │ 2│

│ −│ − │ − │ − │ − │ − │ + │ + │ │ │ │ │ 1│

│ −│ − │ − │ − │ − │ − │ + │ − │ − │ − │ − │ − │ 1│

─────┴────┼────┴────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼───────┼─────

=VIII= =3=│ =Cases= │ │ │ │ │ │ │ │ │ │ │

─────┬────┼────┬────┼────┼────┼────┼────┼────┼────┼────┼────┼────┼───────┼─────

│ −│ − │ − │ − │ − │ − │ − │ + │ │ │ │ │ 2│

│ −│ − │ − │ − │ − │ − │ − │ + │ + │ + │ │ │ 1│

─────┴────┴────┴────┴────┴────┴────┴────┴────┴────┴────┴────┴────┴───────┴─────

(_b_) Eleven of the patients entering as positives became negative, 10

after one week and 1 after two weeks.

This group of cases furnishes no data concerning the duration of the

“carrier” state, since all cases were positive when first observed. In

30 per cent of instances, hemolytic streptococci disappeared within the

first two weeks of observation.

=Groups II to VIII= include 205 patients who became positive at some

time during their stay in the hospital. The arrangement in groups

depends upon the length of time the patients remained in the hospital

before acquiring S. hemolyticus. Ninety-five of these patients had no

further cultures after the initial positive culture. Fourteen appear as

“irregular,” as defined above. These two classes of cases are omitted in

the following summary of these groups. The initial positive culture is

arbitrarily considered the day of infection and subsequent cultures mark

off weekly intervals.

(_a_) Thirty-nine patients had acute infections due to hemolytic

streptococci. Thirteen of these patients passed from observation after

their initial positive culture. The cases with repeated cultures after

initial positive may be summarized as in Table LXIX.

TABLE LXIX

═════════════════════════════╤═════════════╤═════════════╤═════════════

│NO. PATIENTS │NO. BECOMING │ PER CENT

│ CULTURED │ NEGATIVE │ BECOMING

│ │ │ NEGATIVE

─────────────────────────────┼─────────────┼─────────────┼─────────────

Recultured after one week │ 26│ 7│ 26.9

Recultured after two weeks │ 14│ 8│ 57.1

Recultured after three weeks │ 7│ 4│ 57.1

Recultured after four weeks │ 2│ 2│ 100.0

─────────────────────────────┴─────────────┴─────────────┴─────────────

The records within this small group of cases indicate that hemolytic

streptococci tend to disappear with the passing of the acute infection.

(_b_) One hundred and sixty-six contact “carriers” are included in

Groups II to VIII. Eighty-two of these passed from observation after

their initial positive culture and 14 appear as “irregular.” The cases

with repeated throat cultures after the initial positive are summarized

in Table LXX.

TABLE LXX

│NO. PATIENTS │NO. BECOMING │ PER CENT

│ CULTURED │ NEGATIVE │ BECOMING

│ │ │ NEGATIVE

Recultured after one week │ 70│ 26│ 37.1

Recultured after two weeks │ 22│ 9│ 40.9

Recultured after three weeks │ 5│ 5│ 100.0

Recultured after four weeks │ 4│ 4│ 100.0

These records indicate that contact carriers in great part harbor

hemolytic streptococci during short intervals. A longer period of

observation after the disappearance of hemolytic streptococci would have

been desirable in many instances. Some patients were followed with

consistently negative cultures during three, four and five weeks after

hemolytic streptococci had disappeared.

It is difficult to explain those instances in which negative cultures

are interposed between positives. Where one negative interrupts positive

cultures, it is possible that the throat culture failed to demonstrate

hemolytic streptococci which were present. Such cases in this series

fall within the limits of the percentage error of throat culture

identification. Where two or three, or even four negative cultures

intervene, reinfection is not impossible.

=Relation of S. Hemolyticus “Carriers” to the Complications of Acute

Respiratory Diseases.=—In the present study of measles it has been shown

that pneumonia following measles has been no more common in “carriers”

than in “noncarriers.” Nevertheless, pneumonia occurring in badly

infected wards has been modified by streptococcus complications.

More cases of otitis media have appeared in “carriers” than in

“noncarriers.” The possibility that mild otitis media, which would

ordinarily pass unnoticed, might become evident as the result of

streptococcus invasion must be considered. Levy and Alexander have made

an important contribution to our knowledge of the rôle of hemolytic

streptococci in measles. They find that “carriers” of hemolytic

streptococci among measles patients are especially predisposed to

complications following measles.

Their cases were drawn from a camp population highly saturated with S.

hemolyticus “carriers.” In the organization from which 89 per cent of

their patients with measles came, there were 83 per cent hemolyticus

“carriers” among men on duty. Among patients with measles, throat

cultures were positive for hemolytic streptococci on admission in 77 per

cent. It is evident that all patients with measles have been exposed to

hemolytic streptococci during the first day or two after admission.

Failure to carry streptococcus would appear to be dependent upon ability

to resist it rather than upon lack of opportunity for acquiring it. Of

388 cases observed by Levy and Alexander only 79 were “noncarriers” of

hemolytic streptococci on admission, and of these, 27 became positive

while under observation; only 52 remain as “noncarriers” of hemolytic

streptococci. This small group must be regarded as a highly selected

one, composed of individuals more than ordinarily resistant to hemolytic

streptococci and perhaps to all complications of measles. The chances

are that these 52 cases placed under any circumstances might very well

have been among the large number of measles cases in which no

complications develop.

Furthermore, it is not unlikely that any complication of measles may be

modified by a streptococcus secondarily when about 85 per cent of the

cases show S. hemolyticus in the throat. The complications in the cases

of Alexander and Levy appear to have been caused in large part by

streptococcus, but a complete bacteriologic study of them is not

recorded. Complications among streptococcus “carriers” are not identical

with complications due to the streptococcus, and it is desirable to know

what percentage of complications actually due to hemolytic streptococci

occurred among the 85 per cent of patients with measles who carried

hemolytic streptococci.

=Summary.=—No hemolytic streptococcus complications occurred in 112

cases of measles observed at Ft. Riley, among which streptococcus

“carriers” rose from 2.6 per cent on admission to 24.1 per cent before

discharge from the hospital. The percentage of “carriers” of hemolytic

streptococci among normal men in the camp supplying these cases was

about 25.5 per cent.

The influenza epidemic and a small epidemic of measles occurred in part

simultaneously at Camp Pike during September and October, 1918. The

complications following measles at Camp Pike were to a considerable

extent dependent upon the combined effects of influenza and measles.

Thirty-five per cent of the measles patients showed throat cultures

positive for B. influenzæ on admission to the hospital. On repeated

cultures, this rose to 84 per cent before discharge.

Ward separation of cases of measles carrying hemolytic streptococci in

their throats and cases not carrying these organisms were practiced in

handling this epidemic. Of 867 cases of measles treated in this manner,

37 were positive for hemolytic streptococci on admission, and 205

developed positive throat cultures for these organisms during their

period of observation in the hospital.

At Camp Pike, the percentage incidence of S. hemolyticus “carriers,” on

admission to the measles wards, was 4.2 per cent. In cases recultured

after one week, it was 10.9 per cent; after two weeks 22.8 per cent;

after three weeks 26.2 per cent; and after four weeks 33.1 per cent. The

weekly development of “carriers” in the “clean” treatment wards was

during the first week 9.1 per cent; during the second week 17.4 per

cent; during the third week 17.4 per cent; and during the fourth week

17.4 per cent.

The principal complications of these 867 cases of measles at Camp Pike

were: pneumonia, 56 cases; otitis media, 48 cases, with subsequent

mastoiditis in 23 cases, 2 of which had extensions to the meninges and

brain. The greater part of the pneumonia occurred early in the period of

observation, while most of the otitis media occurred later. Incidence of

hemolytic streptococci was low during the pneumonia period and high

during the prevalence of otitis media.

Hemolytic streptococci complicated 9 of these pneumonias; caused a large

percentage of otitis (bacteriology incomplete), and 21 of the 23 cases

of mastoiditis.

The bacteriology of 35 of the 56 pneumonias showed: Pneumococcus Type II

atypical, in 36 per cent, Type IV in 22.9 per cent, Type I in 2.8 per

cent and Type III in 2.8 per cent; hemolytic streptococci in 22.4 per

cent; and B. influenzæ in 88.6 per cent.

The culturing of wards as units revealed widespread contact

dissemination of hemolytic streptococci, at times 25 to 50 per cent of

the patients in a ward becoming “carriers” within the period of a week.

Streptococcus pneumonias, otitis media and its complications were

furnished in large part by wards in which active dissemination occurred.

Streptococcus complications did not occur among 37 patients who were

“carriers” of hemolytic streptococci when admitted to the hospital.

The epidemic dissemination of hemolytic streptococci occurs in measles

wards, and is a serious danger. Many, patients whose throats become

infected, develop no symptoms. In some instances streptococcus invades,

and renders much more serious lesions caused by other microorganisms.

Methods to prevent transfer of infection within the ward and separation

of “carriers” from “noncarriers” in different wards are efficient in

keeping epidemic dissemination of hemolytic streptococci under control.

Frequent throat cultures and prompt report of the results of cultures

are essential.

The dissemination of B. influenzæ in patients with measles was not

controlled by segregation of “carriers” and “noncarriers” of this

organism as identified by throat cultures in separate wards.

Epidemic Respiratory Disease The pneumonias and other infections of the repiratory tract accompanying influenza and measles · 第 8 / 10 章