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.
Chart 5.—Shows the time relation between the identification of hemolytic streptococci in the throats and the development of otitis media in 27 cases shown to be due to hemolytic streptococci. The onset of otitis media is represented by the ordinate marked ○. The number of days before or after the onset of the otitis, within which the throat culture which proved positive for hemolytic streptococci was taken, is marked off along abscissæ to the left and right of ordinate ○ respectively. On the curve plotted these symbols are used: A circle represents a throat culture positive for hemolytic streptococci in a case of otitis media without extension to mastoid. The plus sign represents a throat culture positive for hemolytic streptococci in a case of otitis media with mastoiditis and osteitis.
In this series of cases (Chart 5) the appearance of S. hemolyticus in the throat and the onset of otitis media are very closely associated in those patients in whom further extensions of the streptococcus infection occurred. In instances in which appearance of streptococci and of otitis media are separated by an interval of more than seven days, no further extension occurred. In 8 cases in which this interval is seven days or less there has been no further extension of the infection.
The Dissemination of Hemolytic Streptococci in Wards
Beginning October 24 cultures for the identification of carriers of hemolytic streptococci were made from all patients in a ward and repeated at intervals of one week. Prior to this time individual patients had been examined at intervals of one week, so that an entire ward was never studied on any particular day. This system did not identify and remove all “carriers” in a ward at a given time and was abandoned because it failed to show the conditions present. Investigation of wards as units proved much more satisfactory.