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 WARD | NO. CASES CULTURED | NO. POSITIVE FOR HEMOLYTIC STREPTOCOCCI | PER CENT POSITIVE FOR HEMOLYTIC 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 WARD | NO. CASES CULTURED | NO. POSITIVE FOR HEMOLYTIC STREPTOCOCCI | PER CENT POSITIVE FOR HEMOLYTIC 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.