CHAPTER V

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.

(c) Investigation of the bacteriology of all cases under treatment, by 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.

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.

(_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.

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.