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Chapter XII

Communicable Diseases, Table of Contents

CHAPTER XII

MEASLES

STATISTICAL CONSIDERATIONS

PRIOR TO THE WORLD WAR

During peace times when troops are in garrison, measles is a disease which gives relatively little concern to the medical department of an army; most troops, under such circumstances, having had some years of service, either have had the disease and thus developed an immunity to it, or, having been exposed, have escaped the disease by reason of the fact that they already possessed an immunity. Therefore, during peace times, measles usually has been limited, in so far as serious outbreaks in the Army are concerned, to recruit depots. On the other hand, when the Army has been greatly expanded, as in mobilization for war, the incidence of measles greatly increased. Thus measles has played a very important part during the various wars in which the United States Army has participated.

Chart XLIV has been prepared to show the incidence of measles in the Army for the period 1840-1919.1 Prior to the Civil War, the Army had no colored enlisted men, so figures for white enlisted men only have been used to make the ratios comparable. This chart shows measles increased tremendously with mobilization of the Union Forces for the Civil War. During the years covered by the Civil War statistics, 67,763 cases were reported, with 4,246 deaths among white troops, with a case fatality of 6.27 per cent. Only a small part of this mortality was directly referable to measles;2 in many of the regiments only one death was caused by its epidemic occurrence. Since most of the mortality was the result of secondary pulmonary affections, the rate given does not adequately express the situation, for many deaths were charged to the pneumonic lesion without reference to the primary cause.

Following the Civil War the occurrence of measles decreased, and in the year of 1866 the admission ratio was only 1.98 per thousand strength.3From this time until mobilization commenced for the Spanish-American War (1898), the disease was not one of great importance in the Army. Although certain of the intervening years were marked by distinct increases, yet the annual admission ratio did not exceed 9 per thousand except during the year of 1896, when it became 10.30.4 In 1898, the admission ratio rapidly rose to 51.70 per 1,000 per annum.4From 1899 until the mobilization of troops on the Mexican border in 1916, the occurrence averaged about 8.5 per thousand per annum.5

During the years intervening between the close of the Philippine insurrection (1902) and 1916, serious outbreaks of measles were limited almost entirely to our recruit depots. Thus, during 1911, a severe epidemic, with a 5 per cent mortality, occurred at Columbus Barracks, Ohio.6Of the 1,101 cases, with 25 deaths, in the total Army in the United States in 1911, 392 cases with 18 deaths occurred at Columbus Barracks.6

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.


410

On a small scale, conditions as they existed at Columbus Barracks during the time mentioned are illustrative of what occurred in some of the camps during mobilization for the World War; that is, recruits from all sections of the country were crowded into barracks, and among them were men from rural districts where there was a large percentage of measles nonimmunes. With overcrowding, particularly during the colder months of the year, epidemics inevitably occurred.

CHART XLIV

In greater detail, the comparative trends of cases and deaths for the Civil War, the Spanish-American War and Philippine insurrection, and the World War are graphically shown in Chart XLV, by months of occurrence for white and colored enlisted men. From this illustration it is seen that the peak of admissions occurred in the early period of the respective wars. For the World War, the peak occurred in November, 1917, and subsequent to that time there was a well-marked decline in the admission ratio. During the Civil War, the peak for admissions was reached during the first year, namely, in December, 1861. The peak was also reached early in the Spanish-American War. Since this war was waged during the summer season, measles and its complications did not become an important epidemiological problem. For the World War, the peak, taken by the death rate trend, also was reached in November, 1917. This was not the case in the Civil War, as the peak did not occur until March, 1864. During the second and third winters of the Civil War the death rate rose out of proportion to the number of cases reported. This may be accounted for by improvement in diagnosis during the latter period of the war and in cases being actually charged to measles rather than to its pulmonary complications. The increased death rate may be accounted for by the enlistment of colored troops after July, 1863, as they had higher death rates due to pulmonary complications


411

The number of deaths was not great following measles during the Spanish-American War and Philippine insurrection. The peak, as shown on Chart XLV, was reached in March, 1902.

The admission rate for white and colored troops combined for the entire period of the Civil War, from May, 1861, to June, 1866, was 32.22 per thousand per annum; the death rate was 2.02. During the Spanish-American War and Philippine insurrection, from May, 1898, through June, 1902, the admission and death ratios per thousand strength were 26.06 and 0.32, respectively. For the World War, based on occurrence in the United States and Europe only and from April, 1917, to and including December, 1919, the admission ratio was 25.28 and death ratio 0.63 per thousand per annum. It may be inferred, then, that measles was better controlled during the period of the World War as a whole than during the other two wars under consideration, and while the death rate was twice as high as that for the Spanish-American War and Philippine insurrection, it was less than one-third as high as the corresponding rate during the Civil War.

DURING THE WORLD WAR

Discussions which follow are based, generally, upon the primary admissions. For the total Army the admission, death, and noneffective ratios were 23.79, 0.57, and 1.25 per thousand per annum, respectively. American officers and enlisted men contributed 96,817 admissions, 2,367 deaths, and a loss of time from duty amounting to 1,864,477 days. This occurrence was among the total mean annual strength of approximately 4,000,000 men. Officers, as shown in Table 65, with an aggregate strength of 206,382, contributed 974 admissions and 3 deaths, the loss of time from duty amounted to 12,015 days. The noneffective ratio was 0.16 per thousand per annum. The admission and death ratios were, respectively, 4.72 and 0.01 per thousand, the lowest in the Army where large bodies of troops were concerned. This is probably accounted for by the difference in age and living conditions among officers as compared with enlisted men. Among American enlisted men there were 95,843 primary admissions, with 2,364 deaths. The admission and death rates were 24.66 and 0.61 per thousand strength, respectively, and the loss of some 1,800,000 days, with a noneffective ratio of 1.31 is credited to them. Enlisted native troops, serving in their home territory, had 1,408 primary admissions among a total of a mean annual strength amounting to 36,022. There were three deaths with admission and death ratios of 39.08 and 0.08 per thousand per annum, respectively. From the above it is seen that the highest admission ratios were among native troops, and the lowest among American officers.

It was the opinion of medical officers that deaths did not follow uncomplicated measles, but were due to complications and concurrent diseases. It was the practice in the statistical division of the Surgeon General's Office, as noted elsewhere (p. 5), to charge all subsequent developments to the primary cause of admission to sick report. This accounts for the deaths, permanent disability, and much of the time lost from duty credited to measles in this chapter. Therefore, for a comprehensive understanding of this chapter the reader should take the method of computation into consideration.


412

CHART XLV


413

TABLE 65.-Measles. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and rates per 1,000 

 

Total mean annual strengths


Admissions

Deaths

Discharges for disability

Days lost

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Noneffective ratio per 1,000 strength

Officers and enlisted men including native troops

4,128,479

98,225

23.79

2,370

0.57

149

0.04

1,877,944

1.25

Total officers and men, American troops

4,092,457

96,817

23.65

2,367

.58

149

.04

1,864,477

1.25

Total officers

206,382

974

4.72

3

.01

---

---

12,015

.16

Total American troops:

 

 

 

 

 

 

 

 

 

    

White

3,599,527

90,112

25.01

2,228

.62

142

.04

1,723,795

1.31

    

Colored

286,548

4,870

17.00

116

.40

7

.02

106,551

1.02

    

Color not stated

---

861

---

20

---

---

---

22,116

---

         

Total

3,886,075

95,843

24.66

2,364

.61

149

.04

1,852,462

1.31

Total native troops (enlisted)

36,022

1,408

39.08

3

.08

---

---

13,467

1.02

Total Army in United States, including Alaska:

 

 

 

 

 

 

 

 

 

    

Officers

124,266

813

6.54

1

.01

---

---

9,511

.21

    

White enlisted

1,965,297

80,546

40.98

1,889

.96

138

.07

1,503,341

2.10

     

Colored enlisted

145,826

4,039

27.71

97

.67

7

.05

87,946

1.65

         

Total enlisted

2,111,123

84,585

40.06

1,986

.94

145

.07

1,591,287

2.07

         

Total officers and men

2,235,389

85,398

38.20

1,987

.89

145

.06

1,600,798

1.96

U.S. Army in Europe, excluding Russia:

 

 

 

 

 

 

 

 

 

    

Officers

73,728

124

1.68

1

.01

---

---

2,084

.08

    

White enlisted

1,469,656

7,529

5.12

318

.22

2

.00

189,822

.35

    

Colored enlisted

122,412

668

5.46

19

.16

---

---

16,017

.36

    

Color not stated

---

847

---

20

---

---

---

21,822

---

         

Total enlisted

1,592,068

9,044

5.68

357

.22

2

.00

227,661

.39

         

Total officers and men

1,665,796

9,168

5.50

358

.21

2

.00

229,745

.38

Officers other countries

8,388

37

4.41

1

.12

---

---

420

.14

U.S. Army in Philippine Islands:

 

 

 

 

 

 

 

 

 

    

White enlisted

16,995

107

6.30

---

---

---

---

1,960

.32

    

Colored enlisted

4,456

2

.45

---

---

---

---

38

.02

         

Total enlisted

21,451

109

5.08

---

---

---

---

1,998

.26

U.S. Army in Hawaii:

 

 

 

 

 

 

 

 

 

    

White enlisted

16,161

169

10.46

3

.19

---

---

2,657

.45

    

Colored enlisted

3,319

40

12.05

---

---

---

---

582

.48

         

Total enlisted

19,480

209

10.73

3

.15

---

---

3,239

.46

U.S. Army in Panama: (White enlisted)

19,688

121

6.15

---

---

---

---

1,640

.23

U.S. Army in other countries and not stated:

 

 

 

 

 

 

 

 

 

    

White enlisted

(a)

263

---

2

---

1

---

6,984

---

    

Colored enlisted

(a)

8

---

---

---

---

---

411

---

    

Color not stated

---

10

---

---

---

---

---

263

---

         

Total

14,232

281

19.75

2

.14

1

.07

7,658

1.47

Transports:

 

 

 

 

 

 

 

 

 

    

White enlisted

97,498

1,377

14.12

16

.16

1

.01

17,391

.49

    

Colored enlisted

10,535

113

10.73

---

---

---

---

1,557

.41

    

Color not stated

---

4

---

---

---

---

---

31

---

         

Total

108,033

1,494

13.83

16

.15

1

.01

18,979

.48

Native troops enlisted:

 

 

 

 

 

 

 

 

 

    

Philippine Scouts

18,576

127

6.84

1

.05

---

---

1,412

.21

    

Hawaiian

5,615

186

33.13

---

---

---

---

1,373

.67

    

Porto Ricans

11,831

1,095

92.54

2

.17

---

---

10,682

2.47

aSeparate strength of white and colored not available.


414

OCCURRENCE IN THE UNITED STATES

More than eight-tenths of the primary admissions were among troops serving in the United States. (See Table 65.) There were 85,398 such admissions among the troops serving at home and in Alaska. In so far as Alaska is concerned, for all practical purposes the number of measles admissions there was so small it need not be considered. The total annual mean strength of the Army in the United States was about two and a quarter million men, and among these there were 1,987 deaths. The admission and death ratios were 38.20 and 0.89 per thousand per annum, respectively. The loss of time from duty was considerable and amounted to 1,600,798 days, with a noneffective ratio of 1.96 per thousand. Enlisted men serving in home territory contributed 145 of the 149 cases discharged for disability. There were 84,585 primary admissions for measles among enlisted men, 80,546 of which were among white enlisted men. The annual admission ratio for the total enlisted was 40.06 per thousand strength, the highest experienced by these troops due to measles in any country in which they served. Of the total 2,370 deaths charged to primary admissions, 1,986 occurred among the enlisted men serving at home. The death ratio was 0.94 per thousand. One and a half million days were lost from duty, with the highest noneffective ratio that occurred among American troops serving in any country during the World War. It was 2.07 per thousand strength.

RELATION OF OCCURRENCE TO MOBILIZATION

Apparently no disease was more closely allied to mobilization than was measles. This is shown quite clearly in Chart XLVI. During the fall and early winter of 1917, when mobilization camps were being organized, barracks and tents were overcrowded and inadequately heated, and it was impossible to supply the men with sufficient warm clothing.7These adverse conditions were augmented by an unusually early and severe winter. The draft brought large numbers of persons together from all walks of life and from every environment. The inducted men were principally young adults and included not only the generally immune city boy, but also vast numbers of rural lads who had never before been exposed to the infection.

The influence of introducing large numbers of nonimmunes into the camps during the war is shown by Chart XLVI, which depicts the comparative trend between mobilization and measles. In November, 1918, the drafting of men ceased and recruiting was not resumed until March of the following year. This, of course, tended promptly to bring the measles rate down to a low level. Additional factors which had a tendency to reduce the occurrence of measles in the Army below the 1917 peak were the better housing, clothing, isolation, and heating facilities which became available in 1918. The occurrence, however, ran generally parallel with mobilization. Length of service also, influenced occurrence; in more than two-thirds of the cases the men had had three months' service or less. In other words, the disease developed during the early camp service of the recruit.


415

OCCURRENCE BY CAMPS

Analysis by camps of occurrence in the United States shows great difference in extent to which this disease prevailed. It varied from 1.19 per thousand strength at Camp Syracuse, N. Y., and 7.27 at Camp Dix, N. J., to 164.67 per thousand at Camp Pike, Ark., among white enlisted men. (Table 66.) The location of the camp played no determining rôle; it was largely a matter of one camp drawing a higher percentage of immunes or nonimmunes than another. The maximum occurrence was attributed to troops from the southeastern portion of the country (Chart XLVII). From a study of the population of the eastern portion of the United States, one is justified in saying that the northeastern section is thickly settled while the southeastern is sparsely settled. In other words, the bulk of the population in the former have lived in cities and

CHART XLVI


416

CHART XLVII


417

in close proximity, and as such may be classified as urban. In the latter, or southeastern portion, there are some large cities, but the bulk of the population may be called rural. A large proportion of the inhabitants in urban States have contracted measles in childhood, while in rural States a large percentage have not been exposed to the disease. Applying this information in discussing occurrence by camps, it is noted, for example, that Camp Pike, Ark., which stands at the head of the list, drew its quota of troops from Southeastern States, namely, Alabama, Arkansas, Louisiana, Mississippi, and Tennessee. Camp Bowie, Tex., which stands second, drew its quota from Arkansas, Louisiana, and Texas. Camp Sevier, S. C., standing third, drew from Alabama, Kentucky, North Carolina, and South Carolina. Camp Wheeler, Ga., fourth on the list, drew its quota from Alabama, Florida, Georgia, Louisiana, and Mississippi. On the other hand, Camp Grant, Ill., which drew its quota principally from Illinois, and Camp Dix, N. J., which drew principally from New York and New Jersey, stand at or near the bottom of the list of camps. The last three States are thickly settled and may be classified as urban States; while the other States mentioned, generally speaking, may be classified as rural.

Next to Camp Pike, which had a high rate of occurrence for most of the epidemic diseases, comes Camp Travis, Tex. Camp Pike had 6,730 such admissions for measles among white, and 314 among colored, enlisted men. Camp Travis had 4,484 among whites and 337 among colored. Camp Pike also heads the list in the number of deaths, with a total of 211 men for the period of the war, 197 of which were among white troops. Camp Bowie, on the other hand, had the highest death rate for the period, as shown in Table 66.

From the figures given above it is seen that measles was of far greater importance among white than among colored enlisted men. The comparative occurrence in the two races is illustrated in Chart XLIX, which shows admissions, deaths, case fatality, noneffectiveness, days lost, and discharges for disability among white and colored enlisted men serving in the United States. The admission and death ratios, as well as noneffective ratio and discharges for disability, were greater among white than colored enlisted men. The case fatality and average days lost per case were greater for colored than for white enlisted men.

From the standpoint of epidemiology, the six months period commencing October 1, 1917, marks the measles period for the Army. During this time there were 51,022 primary admissions among white enlisted men, and 1,487 among colored, making a total of 52,509, or more than one-half of the total admissions for the entire Army serving in all countries.


418

CHART XLVIII


419

TABLE 66.-Measles. Admissions and deaths, by camps of occurrence, white and colored enlisted men in the United States, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000.


420

CHART XLIX


421

The occurrence of measles at Camp Wheeler, Ga., may be taken as typical of camp occurrence.8 The construction of the camp was not concluded until November, 1917. The first troops arrived on September 5, and by September 20 practically all of the National Guard troops of the division had arrived, totaling some 11,000 men. Of these, probably 3,000 were recruits of about three months' service. (Measles had been occurring in the regiments since the time of their muster in June, 1916, and most of the regiments had experienced considerable epidemics of both measles and pneumonia on the Mexican border during the winter of 1916-17; the Alabama troops had especially suffered at Nogales, Ariz.) The total sick report was about 3 per cent. On October 14, 1917, the first draft men arrived, about 4,000 in number; others continued to come, until by October 28, over 10,000 had arrived. These inducted men brought measles on every train; cases were taken from trains where they had been shut up for from a few hours to 24 hours or more in closed cars filled with men. It can scarcely be wondered that measles got out of control among these men and among the recruits of the various regiments. The number of admissions which had been 7 on October 19, rose to 14 on October 21, 44 on the 23d, 70 on November 2, 102 on the 5th, 118 on the 7th, and reached its maximum with 174 admissions on November 22. By December 7, the conflagration had burned entirely out. There were approximately 3,000 cases among the 10,000 drafted men. It seemed that there were about 30 per cent of nonimmunes.

The following observations were obtained from the respective histories of base hospitals throughout the United States.9

At Camp Custer, Mich., admissions for measles increased in numbers from the beginning of mobilization; however, the cases were very mild in character and of a type easily confused with German measles. On January 5, 1918, about 2,000 men arrived in this camp from an overcrowded recruit depot in a near-by State. Many of these soldiers were suffering from severe upper respiratory tract infections which included laryngitis, bronchitis, and pneumonia. More than 300 cases were brought to hospital within a few days. The disease, however, was not confined to the new men, but soon spread to others in camp, and the measles cases, which formerly had been mild in character, now became severe and marked the beginning of an epidemic of empyema. It was in January, 1918, that the measles incidence began to assume epidemic proportions.

At Camp Dodge, Iowa, the incidence of measles was associated invariably with an increase in the strength of the command. The weather is said to have played no causative rôle here, as it did in other camps. The high incidence was dependent upon the arrival of new troops, the percentage of susceptibles, possible delay in diagnosis, and cross infections in the base hospital.

Camp Fremont, Calif., reported two epidemics of measles, one late in 1917 and the other in February and March of 1918, neither of which was serious, and only an occasional case of pneumonia as a complication.

In the month of December, 1917, measles made its first appearance at Camp Gordon, Ga., almost immediately assuming epidemic proportions, taxing the capacity of the hospital to its utmost. Among troops from Georgia, Ala-


422

bama, and Tennessee came the overwhelming preponderance of the measles cases, while troops transferred from Camps Upton, Dix, and Lee were relatively free. This difference, as stated elsewhere, was apparently due to the fact that the southern troops came from rural communities and had never been exposed to measles, whereas the northern troops were largely city dwellers.

The most serious epidemic that affected troops at Camp Kearny, Calif., was measles. The number of cases reached its height on January 22, 1918, when 115 cases were admitted to hospital.

About the 1st of November, 1917, measles began to enter the hospital at Camp Lee, Va., and epidemics of this disease occurred thereafter, simultaneously with the arrival of new draft men.

At Camp Funston, Kans., a measles epidemic, beginning about October 18, 1917, and reaching its crest during the week of December 20-28, gradually subsided by February 15, 1918, after which time the disease did not exist in epidemic form. During the interval October 18, 1917, to May 18, 1918, about 3,000 cases were admitted to sick report, among 22,854 hospital admissions, or about 13 per cent.

Measles was constantly present at Camp Shelby, Miss., but at no time reached the point where it could be considered an epidemic. It increased with the advent of new troops, particularly those from the rural districts. The first case was admitted about October 1, 1917, and, up to March, 1918, there were 1,505 such admissions.

At Camp Sevier, S. C., measles began to appear almost immediately upon the arrival of the first troops in the fall of 1917. It assumed epidemic proportions with some 3,500 cases. Within 10 days after the epidemic ceased, measles was reintroduced into camp by the arrival of new troops.

Camp Travis, Tex., reported 4,203 cases of measles. The height of the epidemic occurred in the latter part of November and early in December, 1917. The maximum number of admissions was 175 per day. This epidemic died out about the middle of January and was followed by a smaller one in March, 1918, which persisted for about two months.

At Camp Merritt, N. J., both measles and German measles were camp infections during the early months of mobilization; however, not to a serious degree. The fact that the two diseases coexisted made their handling rather difficult as differential diagnosis was not easy. The number of cases was small as compared with the occurrence in many other camps. Up to July 30, 1918, 963 cases of measles and 93 of German measles were admitted to the hospital. In the three weeks preceding the outbreak of influenza in the fall of 1918, an epidemic of measles occurred, chiefly among the soldiers from Camp Gordon.

OCCURRENCE IN THE CIVIL POPULATION

The medical profession accepts measles as a disease of childhood because approximately 90 per cent of the cases in civil life occur before the age of 10 years. The occurrence of measles in all ages, in the civil population is not exactly comparable with the occurrence among the age groups as represented by


423

soldiers, yet even with the added age groups of the civil population it will be shown that measles had a greater occurrence ratio in the Army than among the home population. Table 67 shows the reported cases of measles and deaths, with ratios per thousand in the registration area of the United States during the period 1917-1919. The population is estimated and taken from public health records for the year 1918, and the total ratios for the respective years are based upon this population. This table shows that 529,498 cases were reported in the registration area among a population of approximately 100,000,000 persons of all ages; the annual ratio was 5.29 per 1,000 for the year 1917. During this year 9,466 deaths were reported, giving an annual death ratio of 0.09 per thousand. During the same year the admission ratio in the Army was 92.24 per annum and the death ratio 2.18. In other words, although all ages are included in the civilian occurrence, including the ages in which measles is most prevalent, the disease was approximately eighteen times more common in the Army than among the civilian population. In this connection, however, it should be remembered that these figures include only reported cases in the registration area, and undoubtedly many cases, as well as deaths, occurred that were never reported.

During 1918 the disease was less prevalent in the United States than it was in 1917, both among civilians and soldiers; in the registration area 429,764 cases and 9,944 deaths were reported, with occurrence and death ratios of 4.29 and 0.099 per thousand per annum, respectively, while in the Army in the United States, during the same period, among enlisted men there were, 38,447 primary admissions, with 908 deaths. The admission and death ratios were, respectively, 29.29 and 0.69 per thousand strength. During the following year (1919) the number of cases and deaths was considerably less. In the civil population there were 178,528 cases reported with 2,316 deaths, while in the Army 1,211 primary admissions, with 18 deaths, were recorded among enlisted men. The occurrence ratio in the civil population was 1.78 and death ratio 0.02 per thousand, while these ratios in the Army were 3.95 and 0.06 per thousand strength. Therefore, it may be said that measles was prevalent in the civil population in the beginning of the war and decreased in its occurrence throughout this period. The same may be said for the occurrence in the Army.


424

TABLE 67.-Measles and population, United States registration area, all ages, by States of occurrence, showing estimated population July 1, 1918. Admissions and deaths. Absolute numbers and ratios per 1,000a


425

OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

Among the total of the mean annual strengths for the American Expeditionary Forces of 1,665,796 officers and men, there were recorded 9,168 primary admissions for measles and 358 deaths. The admission and death ratios per thousand strength, respectively, were 5.50 and 0.21. Among these cases there was a loss of time from duty amounting to 229,745 days, giving a noneffective ratio of 0.38 per thousand per annum.

The vast majority of cases were among white enlisted men. (See Table 65.) These troops contributed 7,529 of the primary admissions, a ratio of 5.12. Colored enlisted men contributed 668 primary admissions with a ratio of 5.46 per thousand strength. Of the total deaths, 318 were among white enlisted men and 19 among colored. There was 1 death among officers and 20 among enlisted men, whose color was not stated. The loss of time from duty among white troops amounted to 189,822 days, and for colored, 16,017. The noneffective annual ratios were, respectively, 0.35 and 0.36. From these figures it is apparent that the occurrence of measles and the noneffectiveness were greater among colored than among white troops. The death ratio, however, was higher for the latter.

Occurrence by months is better shown with figures for white than with figures for colored enlisted men. The first cases among white troops were reported during the month of June, 1917, when 7 primary admissions were recorded. The number steadily increased until January, 1918, when 507 primary admissions were recorded. During the spring there were from 100 to 200 cases per month; however, commencing in the late summer, the number of cases increased until between 800 and 900 primary admissions were recorded per month, with the largest number of cases during September. In 1919, the number of primary admissions was small, due to the withdrawal of the forces from Europe and the discontinuance of forwarding troops from the United States. This applies to the beginning of 1919 and not to the latter part, as recruiting was resumed and replacements sent to the army of occupation in Germany during the latter half of the year, thus accounting for the increase in occurrence among those troops.

Chart L shows the trend taken by admissions and deaths for enlisted men serving in Europe. The peak was reached in July, 1917. This was followed by a decrease until September, when the trend again took an upward course, reaching a second but lower peak in November. Until February, 1918, the admission ratio remained between 25 and 50 per thousand, after which time the occurrence took a downward trend until April. From that time until the date the armistice was signed the trend of occurrence was about horizontal. The occurrence diminished in December and continued through January, 1919. Commencing in the summer, the trend suddenly took an upward course, reaching approximately 9 per thousand, followed by sudden decrease in September, reaching the lowest admission ratio for troops in Europe during the war. During October, 1919, the trend was upward, reaching approximately 35 per thousand; this was due to replacements sent to Germany as mentioned above.


426

Emerson,10 in a report on communicable diseases in the American Expeditionary Forces, stated that 8,207 cases of measles and 86 deaths occurred between July 1, 1917, and April 30, 1919, giving a case mortality of 1.05 per cent. He explained that the high incidence rates in the first months, up to and including January, 1918, as compared with the rates after that time, were probably due to the fact that among troops who came over before the spring of 1918 there was a very much higher percentage of men who had not passed through measles or been exposed to epidemics in the training camps in the United States than was the case with troops arriving in the American Expeditionary Forces after February, 1918. In the first 18 months of the American Expedi-

CHART L


427

tionary Forces, measles was very largely confined to troops just arriving at base ports, or to detachments of recent arrivals at the replacement camps or army units to which they were often hastily forwarded without being held over the incubation period. Between 50 and 80 per cent of all cases in the American Expeditionary Forces were reported from week to week in base ports-that is, up to the signing of the armistice. The number varied greatly according to the arrival of transports or convoys. After the discontinuance of new troop arrivals and the stabilization of commands, measles played but an insignificant part among diseases in the American Expeditionary Forces. The cases that did occur after January 1, 1919, were chiefly in other parts of the American Expeditionary Forces than the base ports, especially in the armies and in the advance sections. Contrary to the general belief, as expressed by medical officers in the United States, Emerson held that measles, as a precedent or contributing cause to pneumonia, played a very unimportant rôle in the American Expeditionary Forces, as it was rare.

There is no reason to believe that measles in the American Expeditionary Forces was to any noticeable extent due to infections acquired by the soldiers from association with the French civil population.10

FACTORS INFLUENCING OCCURRENCE

It is generally accepted that one attack renders the individual lastingly immune. Recurrences in unquestionable cases are rare; therefore, with a disease so markedly contagious as measles, it is reasonable to assume that persons who have lived in close contact with others have developed measles in early life. This explains the larger percentage of immune persons among city dwellers and the susceptibility among country persons. These comparative facts are borne out by occurrences among recruits and drafted men obtained from urban and rural districts for the Army.

It is generally conceded that mobilization has a direct bearing on the occurrence of measles. This is due to the huddling together of susceptibles, a condition that can not be prevented in military life. During the World War many of the men were not only housed in standard barracks, but they also had a common mess and a common amusement hall.11 In all these places they came in close contact while indoors. Some camps had central heating plants, while others had one or more stoves in each room.11 The former camps were generally located in the northern portion of the United States; the latter were generally in camps located in the South.11 Where heat was evenly distributed throughout the rooms, as in steam-heated barracks, men did not huddle together so much for the purpose of keeping warm or for amusement; in camps where stoves were used, men would collect around the stoves,7and while in this close contact the virus of respiratory diseases was spread through droplet infection. Coughing, sneezing, and spitting were common. Outdoor exercises and duties, such as close-order drill, may have contributed to the spread of the disease, but certainly to a far lesser degree.

The occurrence of measles in the Army shows that it is most prevalent in the cold months. It is true it occurs during all months, but overcrowding is most common in cold weather, and as a result all acute respiratory diseases are


428

then more common. With a large number of recruits suddenly brought into camp, collected from every environment-immunes, persons actually suffering from the disease, and susceptibles-often arriving in camp on the same train, in the same cars, and placed in the same barracks, outbreaks were inevitable.

Race as a factor is subject to question. Measles was more common among white than among colored troops. On the other hand, the Porto Ricans suffered more than any other troops in the American Army, the occurrence being more than three times that among the whites. The Hawaiian troops serving in their own country suffered second. There appears to be no explanation for the greater susceptibility of these persons over negroes. The difference in the records may be explained by the increased difficulty in diagnosing this disease among colored persons.

The importance of measles to the Army during the World War, en grosse, and the relative importance among the several racial constituents, are shown in Table 68. The comparative occurrence during the World War of measles among white and colored enlisted men from the South and from other sections of the United States is shown in Table 69. The occurrence was approximately four times greater among southern white enlisted men than among white troops from the other sections of the country. About the same is true for southern colored enlisted men. Not only was this true for admission ratios, but also for death ratios. The case fatality was slightly higher among the southern white enlisted men, while southern colored enlisted men had a fatality slightly below that of colored enlisted men from the other sections of the United States.

TABLE 68.-Measles. Admissions, deaths, discharges for disability, and days lost, by race, enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

Race


Absolute numbers

Annual ratios per 1,000 strength

Per cent

Admissions

Deaths

Discharges for disability

Total days lost

Days lost per case

Admissions

Deaths

Discharges for disability

Non-
effective

Case fatality rates

Case discharged for disability rates

White

90,112

2,228

142

1,723,795

19.1

25.01

0.62

0.04

1.31

2.47

0.16

Colored

4,870

116

7

106,551

21.9

17.00

.40

.02

1.02

2.38

.14

Filipino

127

1

---

1,412

11.1

6.84

.05

---

.21

.79

---

Hawaiian

186

---

---

1,373

7.4

33.13

---

---

.67

---

---

Porto Rican

1,095

2

---

10,682

9.8

92.54

.17

---

2.47

.18

---

Color not stated

861

20

---

22,116

25.7

---

---

---

---

2.32

---


     Total Army
    (entlisted men)

97,251

2,367

149

1,865,929

19.2

24.80

.60

.04

1.30

2.43

.15

TABLE 69.-Measles. Admissions, deaths, and case fatality rates, white and colored enlisted men, United States Army, by sections of the United States, April 1, 1917, to December 31, 1919

 


Absolute numbers

Annual ratios per 1,000 strength

Case fatality rates (per cent)


Admissions

Deaths

Admissions

Deaths

Southern white enlisted men

41,581

1,136

66.87

1.83

2.73

White enlisted men from other sections of the United States

46,494

1,071

16.53

.38

2.30

Southern colored enlisted men

4,220

103

21.48

.52

2.44

Colored enlisted men from other sections of the United States

487

13

6.79

.18

2.67

Total white enlisted men

88,075

2,207

25.64

.64

2.51

Total colored enlisted men

4,707

116

17.55

.43

2.46

 


429

Officers suffered less than enlisted men. (See Table 65.) There are two possible explanations for this: First, officers lived in individual billets or with one or several other officers; overcrowding was the exception; their relationship to enlisted men did not bring them in close contact with them. Second, officers represented an older age group, and as such had greater opportunities for having contracted the disease at some prior date. The individual billeting of officers deserves chief attention in explaining why officers suffered less than enlisted men from measles.

An analysis was made of 28,837 primary admissions for measles, white enlisted men, to determine the influence of length of service on the occurrence of measles. Among this number, 11,528 men had less than two months' service when they were admitted to sick report. Including men with three months' service, in 20,991 instances, measles occurred before these men had been in the service 100 days. This, as will be explained below, was a matter of much importance. Continuing the analysis further, it will be seen that the number of cases progressively decreased with each additional month of service for the first year, which contributed 28,002 of the 28,837 cases analyzed.

SYMPTOMS

Repeated observations made by medical officers lead one to believe that measles has perhaps one of the most constant periods of incubation for any of the eruptive diseases; that is, reckoned from the date of exposure to the appearance of the eruption. It was 13 days, and, in fact, was so regular that the 14-day quarantine period was considered entirely satisfactory. Reckoned from the date of exposure to the period of invasion, the time varied from 9 to 11 days. This seemed to represent the consensus of opinion of medical officers.

The period of invasion is the most important stage from an epidemiological point of view. It is characterized by headache, chilliness, fever, mild catarrhal manifestations of the eyes, nose, throat, and bronchi, and cough. During this stage the individual does not feel sufficiently sick to report sick or be confined to bed. It is usually impossible to diagnose the disease during the early stages of this period, and, since the nasopharyngeal secretions have been proven to contain the virus during the stage of invasion, and since the soldier associates freely with his comrades during this time, the great danger of spreading the infection is obvious. Accordingly, the Office of the Surgeon General, the chief surgeon, A. E. F., and camp epidemiologists throughout the Army, repeatedly emphasized the importance of recognizing early symptoms of the disease. The initial symptoms, namely, coryza and catarrhal manifestations of the eye, suggest that the infectious agent develops first in the respiratory tract, but the primary lesion is not known.

This period merges into the period of eruption, which manifests itself by an enanthem and an exanthem. The first changes, the enanthem, are seen in the mucous membrane of the mouth and throat as a catarrhal injection. On the buccal surface, Koplik spots appear. Hackett12 stated that at Camp Upton, N. Y., inspections were made of suspects twice daily, when Koplik spots and eruption were carefully looked for. These spots, however, were never seen. The Koplik spots were looked for as a routine in measles cases and suspects in


430

the Army during the war, but their presence was only occasionally reported. Generally speaking, cases in the Army were seen late in the period of invasion and usually the diagnosis was not made until the skin eruption had developed, by which time the Koplik spots are lost in the eruption on the mucous membrane of the mouth.

The exanthem appears as red, flat, slightly elevated papules developing in from three to five days after the beginning of catarrhal symptoms. It is first noticed on the temples, neck, forehead, and about the edge of the hair. The eruption has a dusky hue as distinguished from the bright red of scarlatina. From these locations it spreads over the body. It was during the early eruptive period that the vast majority of cases were admitted to our military hospitals during the World War.

The period of desquamation is characterized by a fine furfuraceous peeling of the epidermis, involving also the palms of the hands and soles of the feet. It lasts one or two weeks and is present in all cases; however, where the skin is oiled it may not be noticeable. In years gone by, it was a practice to hold patients in quarantine in military hospitals until this desquamation was complete. The scales are now looked upon as harmless and, therefore, of practically no value except in diagnosis. Although measles without eruption is recognized, there is no discoverable record of such cases in the Army.

The urine often shows albumin, especially during the febrile period, and the diazo reaction is positive in about three-quarters of the cases. The latter may be of diagnostic value, especially when confusion with scarlatina exists. This test was only sparingly used during the war.

The blood picture is not characteristic. During the period of incubation there is a leucocytosis involving the polynuclear cells. In the period of invasion the number of white cells decreases; during the period of eruption there is a leucopenia; during desquamation, the number rises to normal in uncomplicated cases. This blood picture was considered of some value in the contagious service at the base hospital, Camp Grant, Ill., during the fall of 1917 and winter of 1918, especially in distinguishing measles from scarlet fever.13

Several types of measles are recognized, depending upon severity such as mild, hemorrhagic, malignant, and relapsing. Generally speaking, the disease, as reported, was mild in the Army during the war, but not without exception.

Hamburger and Fox,14reporting upon two measles epidemics at Camp Taylor, Ky., said the first epidemic was quite severe and the majority of patients were acutely ill from the start. The soldiers who later developed pneumonia and empyema, were particularly prostrated upon entrance to hospital, with flushed face, dusky cyanosis, full, bounding pulse, dyspnea, and labored, grunting breathing. The cyanosis was most striking, as one could almost tell from the color of the patient on admission to hospital that he was to develop or was already developing acute pneumonia. The type of pneumonia varied; however, in most instances it was grouped as diffuse lobular or bronchopneumonia. This first epidemic occurred during September, October, and November, 1917; the second epidemic, which occurred in March, April, and May, 1918, was complicated not only by measles-pneumonia but also by a


431

streptococcus epidemic, and was distinctly more severe than the first epidemic. Patients came into the hospital more acutely ill and prostrated than during the first epidemic, and died in considerably higher numbers. They died in spite of treatment, and nothing that could be done made the slightest impression on their condition.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

In barracks where soldiers are housed, as well as in civilian institutions, such as asylums, schools, and other places where large numbers of persons live in dormitories, measles is more commonly followed by complications than where cases occur and are treated in the better class of private homes. This is due to cross infection by carriers, not of the measles virus but of such organisms as the streptococcus, which spreads principally through droplet infection.

Among the 98,225 primary admissions to sick report during the World War with the diagnosis of measles, there were reported 22,809 complications, sequelæ, and concurrent diseases. This does not mean that 22,809 cases of measles developed conditions directly attributable to it. This was the number of such diagnoses made after the individuals were admitted to hospital.

The more important complications and concurrent diseases reported among the primary admissions for measles during the war are given in Table 70. As has long been known, the most important and frequent complications of measles are the pneumonias and otitis media. Experience during the war was no exception to this rule.

TABLE 70.-Measles. Concurrent diseases and complications, enlisted men in the United States and Europe, April 1, 1917 to December 31, 1919

Concurrent diseases and complications


Admissions

Deaths

Case fatality rates (per cent)


Absolute numbers

Ratios per 1,000a

Absolute numbers

Ratios per 1,000a

Bronchopneumonia

4,463

47.67

1,584

16.92

35.49

Otitis media

3,926

41.93

122

1.30

3.11

Lobar pneumonia

1,820

19.44

602

6.43

33.08

Mumps

1,028

10.98

21

.22

2.04

Suppurative pleurisy

645

6.89

268

2.86

41.55

Mastoiditis

566

6.05

18

.19

3.18

Scarlet fever

344

3.67

9

.10

2.62

Tuberculosis of lungs

343

3.66

31

.33

9.04

Diphtheria and results

149

1.59

9

.10

6.04

Erysipelas

149

1.15

14

.15

12.96

Serofibrinous pleurisy

105

1.12

28

.30

26.67

Cerebrospinal meningitis (epidemic)

93

.99

37

.40

39.78

German measles

38

.41

---

---

---

Pericarditis

34

.36

18

.19

52.94

Keratitis

31

.33

---

---

---

Endocarditis, acute

23

.25

8

.09

34.78

Acute miliary tuberculosis

9

.10

9

.10

100.00

Others

9,084

97.02

428

4.57

4.71

    


     Total

22,809

233.22

3,206

32.64

14.06

aRatio per 1,000 of measles.

Table 70 shows 4,463 cases of bronchopneumonia, with 1,584 deaths. The admission and death ratios per 1,000 cases of measles were 47.67 and 16.92, respectively; the case fatality was 35.49 per cent. The next most common


432

complication was otitis media. There were 3,926 cases of measles reported with this complication, of which 122 resulted fatally. The otitis media developed in 4.2 per cent of the cases. The third most common complication was lobar pneumonia; there were 1,820 such cases, with 602 deaths. The admission and death ratios per 1,000 cases of measles were 19.44 and 6.43, respectively, the case fatality was 33.08 per cent. It is generally conceded that lobar pneumonia is not a common complication of measles; lobular or bronchopneumonia is the type usually seen. A review of some of the clinical records indicates that not all diagnoses of lobar pneumonia following measles were correct, and that in some instances at least the diagnosis should have been bronchopneumonia.

Pleurisy was not an uncommon complication-there were 645 cases of suppurative pleurisy and 105 of the serofibrinous variety recorded among the primary admissions. There were 296 deaths reported among these cases. The case fatality with suppurative pleurisy was 41.55 per cent. The cases were preceded by pneumonia. Mastoiditis was recorded in 566 cases following otitis media. Among these there were 18 deaths, a case fatality of 3.18 per cent. Pericarditis was present in 34 cases, 18 of which terminated fatally, with a case fatality of 52.94 per cent. These cases, too, were preceded by pneumonia. Acute endocarditis was recorded in 23 cases, with a case fatality of 34.78 per cent. Eye symptoms are common in measles, and the condition is usually one of catarrhal conjunctivitis, with some photophobia. Phlyctenular keratitis is not an infrequent complication or sequel of measles among children who live in poor hygienic surroundings. It is not commonly seen among the better class of people. Keratitis was recorded in 31 cases.

It has long been considered that measles in some way tends to activate quiescent tuberculosis. Among the total primary admissions for measles, 343 cases of pulmonary tuberculosis were reported, a ratio of 3.66 per 1,000 measles. Among these cases were 31 deaths, a case fatality of 9.04 per cent. Acute miliary tuberculosis was reported in 9 instances and, as usual, terminated fatally.

Francine,15at Camp Gordon, Ga., made a statistical review of pulmonary tuberculosis among convalescent measles cases of the 82d Division there. Orders were issued directing that all measles convalescents be examined for pulmonary tuberculosis one month after return to duty from the hospital. As a severe epidemic had occurred, it was possible for the camp tuberculosis and cardiovascular board to examine and follow up 513 cases, which was about one-third of the total that had been discharged from hospital up to that time. Among these cases the lungs were reported as normal in 461, acute bronchitis in 18, clinical evidence of chronic active pulmonary tuberculosis in 16. In other words, of the 513 cases examined, 16, or 3.11 per cent, showed signs of active pulmonary tuberculosis. All of these cases were discharged from the service on surgeon's certificate of disability. Francine compared these statistical data with the results of the tuberculosis board which had examined the entire division. The tuberculosis rate for the division was reported as 0.92 per cent, and it would appear at first sight as if measles had been an important factor in reactivating the old lesions. This is subject to question, as the convalescents were more thoroughly examined than was the division, and the diagnosis in the 16 cases mentioned above was made after more refined and detailed examina-


433

tion. He concluded that while 3.11 per cent accurately represents the number of cases of active pulmonary tuberculosis in this special group, it is too high if interpreted as an index for measles as a factor in the lighting up of old tuberculous foci.

The findings by Francine are greatly in excess of those reported by Berghoff,16at Camp Grant, Ill., after having made a survey of 596 cases to determine the relationship of measles to pulmonary tuberculosis. These cases were first examined 14 days after admission to hospital and again at 30 days or 6 weeks after admission. All of these patients had previously been examined for tuberculosis while in camp during the routine examination. Only three of the convalescents showed unmistakable signs of a recent reactivation of an old tuberculosis directly attributable to measles infection. Of these three cases, one had suspicious findings after the second examination; the second case was a frank reactivation hut, upon looking up the records, it was found that he had been under observation for tuberculosis one week prior to admission to hospital for measles; the third case was a frank example of an active pulmonary tuberculosis resulting directly from measles infection. Berghoff concludes that these figures seem to show that measles is not a predisposing factor toward pulmonary tuberculosis.

Whether or not measles predisposes individuals to the occurrence of other exanthematous diseases is not known. Among the primary admissions for measles, scarlet fever occurred as a concurrent disease in 344 cases, diphtheria in 149, erysipelas in 108 and German measles in 38. (See Table 70.) Epidemic cerebrospinal meningitis was concurrent in 93 instances and mumps in 1,028.

Hamburger and Fox,14reporting on epidemics of pneumococcus, streptococcus, and measles infections at Camp Taylor, Ky., remarked that these epidemics could be chronologically arranged in five periods. The first, covering September, October, and November, 1917, was designated as the lobar pneumonia period. The second, from November, 1917, to and including January, 1918, was known as the first measles and measles-pneumonitis period. There were 967 cases of measles during this period, 80 of which developed pneumonia and 18 died; the case mortality was 19.4 per cent. Empyema followed measles-pneumonia in 18 cases, with a case fatality of 33.33. The third period, December, 1917, to February, 1918, was designated as the streptococcus atpyical pneumonitis and pleuritis period. Of great interest in this series of cases was the rapid and extensive development of empyema and the presence of hemolytic streptococcus in the pleural exudate. The fourth period was known as the second measles, measles-pneumonia, and streptococcus epidemic. It covered March, April, and May, 1918. During this time there were 414 cases of measles, of which 64 developed pneumonia and 17 died-a case mortality of 31 per cent, as compared with 19.4 per cent in the first epidemic. Empyema followed measles-pneumonia in 15 instances, with a case mortality of 13 per cent. This second measles, measles-pneumonia, and streptococcus epidemic was distinctly more severe than the first epidemic. Patients came into the hospital more acutely ill and prostrated during the latter group and


434

died in considerably higher numbers. It is also noted that twice the number developed empyema, 3.6 against 1.8 per cent, although the empyema mortality was lower. The reason given for this lower mortality was improvement in the methods of treating empyema. It was noted in the second epidemic that this form of pneumonia and streptococcus sepsis occurred often before empyema had time to develop, and these cases of measles, with associated streptococcus sepsis and a very high mortality, were among the most severe types of disease encountered at Camp Taylor, being comparable only with cases of profound general sepsis and profound toxemia. The fifth period marked the decline of the epidemics and was for May, June, and July, 1918. During this time there were 396 cases of measles, of which 9 developed pneumonia and died. The case fatality was 11.11 per cent. The total number of pneumonias of all classes was 114, of which 8 died, giving a case fatality of 7.9 per cent. The total number of empyemas was 26, with a case fatality of 15.4 per cent. This fifth period is interesting, as it showed marked improvement in morbidity and mortality conditions with the advent of warmer weather, although at no time was the camp entirely free from infection.

As a concurrent disease, measles was reported in 3,714 cases, with 162 deaths. These were admitted to hospital for other causes and the diagnosis of measles was made subsequently. Concurrent with scarlet fever, measles occurred in 114 cases, with 7 deaths; smallpox, 5 cases, no deaths; diphtheria, 23 cases, no deaths; German measles, 21 cases, no deaths; epidemic cerebrospinal meningitis, 32 cases, 17 deaths; mumps, 436 cases, 1 death; pulmonary tuberculosis, 141 cases, 3 deaths; bronchopneumonia 104 cases, 15 deaths; lobar pneumonia, 55 cases, with 5 deaths; influenza, 1,529 cases, with 92 deaths.

During the autumn of 1918, the influenza pandemic period, Sellards,17 working at Camp Devens, Mass., investigated the occurrence of the influenza bacillus in cases of measles. These studies were conducted immediately after the subsidence of the influenza epidemic, when the Pfeiffer bacillus may have been unduly prevalent. Of the first 31 cases of measles examined, the Pfeiffer bacillus was recovered in 25 during the eruptive stage. Subsequent examinations showed that in three-fourths of these patients the bacillus disappeared with the subsidence of the acute symptoms of measles. A group of control individuals, seven in number, were examined, but no Pfeifferlike organisms were recovered; several reexaminations of the control group resulted negatively. No experimental evidence was obtained to show that these Pfeifferlike organisms have any etiologic relationship to measles.

Bronchopneumonia, the most important of complications, reached its apex of occurrence in January, 1918. The rate declined during February, with a slight increase in March. During 1918, 544 deaths were attributed to this complication. Lobar pneumonia occurred most frequently as a complication in January, following which there was a decline.

An analysis was made of 1,619 clinical records of cases of bronchopneumonia following measles to determine the relationship of such cases to length of service. (Table 71.) Bronchopneumonia was most common among troops with two months' service or less and decreased with each additional month up to and including one year. After that time the number of cases was too small


435

on which to base any definite conclusions. These same facts apply equally well to deaths. During the first three months of service or less, there were 1,283 of the 1,619 cases and 496 of the 625 deaths; that is, 79.1 per cent of the cases and 79.3 per cent of the deaths. A similar analysis (including 532 cases) was made of lobar pneumonia. (See Table 72.) As with bronchopneumonia, the majority of cases were reported during the first two months of service, and each additional month showed a distinct diminution, not only in cases but also deaths. Of the cases analyzed, 389, or 73.1 per cent, occurred during the first three months of service and 160 of 213 deaths. These occurrences are to be expected when it is seen that measles was most prevalent during the first two months of service, and that it decreased progressively by months thereafter.

TABLE 71.-Measles with bronchopneumonia. Admissions, deaths, and discharges for disability, by length of service, white enlisted men in the United States, April 1, 1917, to December31, 1919

Length of service


Absolute numbers

Percentage rates

Admissions

Deaths

Discharges for disability


Case fatality

Case discharges

Less than 2 months

712

298

12

41.85

1.69

2 to 3 months

571

198

11

34.68

1.93

4 to 5 months

196

84

8

42.86

4.08

6 to 7 months

92

32

2

34.78

2.17

8 to 9 months

17

8

---

47.05

---

10 to 11 months

6

---

---

---

---

1 year

4

---

---

---

---

2 to 4 years

14

5

---

35.71

---

5 to 9 years

6

---

---

---

---

10 to 19 years

1

---

---

---

---

TABLE 72.-Measles with lobar pneumonia. Admissions, deaths, and discharges for disability by length of service, white enlisted men in the United States, April 1, 1917, to December 31, 1919

Length of service


Absolute numbers

Percentage rates

Admissions

Deaths

Discharges for disability


Case fatality

Case discharges

Less than 2 months

236

97

5

41.10

2.12

2 to 3 months

153

63

7

41.17

4.58

4 to 5 months

92

33

6

35.87

6.52

6 to 7 months

34

15

---

44.12

---

8 to 9 months

5

3

---

60.00

---

10 to 11 months

3

---

1

---

33.33

1 year

2

---

---

---

---

2 to 4 years

6

1

---

16.67

---

5 to 9 years

---

---

---

---

---

10 to 19 years

1

1

---

100.00

---

Vaughan,18discussing the occurrence of measles in the Army camps during the winter of 1917-18, emphasized the importance of complications. At Camp Cody, N. Mex., among 235 cases of measles, 77, or 33 per cent, developed pneumonia, and 42 per cent died. Not only did measles predispose to pneumonia, but predisposed to a fatal pneumonia. Among each 1,000 men with measles, 44 had pneumonia and 19 died, and of every 1,000 men without measles, 17 had pneumonia and 2 died. Vaughan further remarked that a person who has recently had measles is ten times more likely to die from pneumonia than a person who has not recently had measles.


436

BACTERIOLOGY OF COMPLICATIONS

The most important bacteria concerned in measles complications during the World War were the streptococcus, pneumococcus, tubercle bacillus, and influenza bacillus. More information is necessary before one can state definitely the relationship that the Pfeiffer bacillus bears, not only to measles but to influenza. The rôle played by the tubercle bacillus is one of reactivation. It is supposed that measles infection predisposes to the lighting up of old tuberculous processes, especially of the lung. The relationship of the streptococcus and pneumococcus in measles had been under investigations for many years, but interest in this subject was increased by the widespread occurrence of measles and its complications in the Army during the war.

Inflammation of the respiratory tract during an attack of measles readily permits the invasion of pathogenic bacteria. Irons and Marine,19at Camp Custer, Mich., made important observations showing that the hemolytic streptococcus had been the principal cause of bronchopneumonia outbreaks following measles in the military camps. Cole and MacCallum20 reported, during their investigations at San Antonio, Tex., that the Streptococcus hemolyticus was present in cultures of sputum coughed up from the deeper parts of the respiratory tract in 30 cases of post-measles bronchopneumonia, and mice, inoculated with sputum from 17 cases, yielded the streptococcus in 16. Blood cultures taken during life yielded the Streptococcus hemolyticus twice in 15 cases. Of the 30 cases, death occurred in at least 14, and in all the Streptococcus hemolyticus was found in the lungs in practically pure cultures. The abdominal organs were found to be free from streptococcal invasion; however, areas of interstitial bronchopneumonia were characterized by streptococcal bronchopneumonia with the streptococcus present in the pleural exudate. In the purely lobular pneumonia areas they were present in amazingly large numbers. According to Hektoen,21 measles patients seem to become infected with hemolytic streptococci by direct droplet infection, contact, and dust infection by way of the throat; the infection also appears to spread more easily in military camps and in measles wards. Irons and Marine19 found that the Streptococcus hemolyticus developed in the throat cultures of approximately 70 per cent of healthy soldiers during a period of respiratory infections. Cumming, Spruit, and Lynch22 reported that, while 35 per cent of measles patients had streptococci in the throat, this was the case in only 6 per cent of healthy soldiers. Cole and MacCallum20 found that 56.6 per cent of the patients in a measles ward harbored the Streptococcus hemolyticus in the throat, as compared with 21.4 per cent in a suspect tuberculosis ward. They also found the Streptococcus hemolyticus in throat cultures of 11.4 per cent of measles patients on admission to hospital; after a duration of from 3 to 5 days in the ward, the per cent increased to 38.6, and after 8 to 16 days to 56.8 percent. These observations, according to Hektoen,21 point unmistakably to the ease with which the Streptococcus hemolyticus passes from carrier to noncarrier and, in measles convalescence, sets up broncho-pneumonia and empyema.

Levy and Alexander,23 discussing the susceptibility of measles convalescents to streptococcus infection at Camp Taylor, Ky., showed that complications and sequelæ were responsible for long hospitalization and high noneffective rates.


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A careful study was made of 388 cases. On admission to hospital, all cases were sent to a special ward where they remained in bed, and from them daily cultures were made for the streptococcus. Carriers of this organism were placed in "dirty wards," or wards where patients were known to be infected with this organism. Patients with negative throat cultures were held for a second examination. If negative on the second examination, such cases were transferred from the observation ward to "clean wards." Cultures were taken from the tonsils and pharynx and plated on human blood agar; bronchial cultures were made when possible. The results of bronchial cultures conformed to those of the throat cultures, therefore the former furnished no special information. Of the total cases examined, 89 or 22.9 per cent were noncarriers and 299 or 77.1 were found to be carriers. This is in marked contrast to the San Antonio findings, where only 11.4 per cent of measles cases were reported as carriers of the streptococcus hemolyticus.20 At Camp Taylor, Ky., the investigators found that of the noncarriers, 27 became carriers while in hospital, and of the 388 cases studied, 119, or 30.6 per cent, developed complications; of the latter, all except 4 were among noncarriers.23The complications that developed in the noncarriers were acute tonsillitis, 1 case; acute bronchitis, 2 cases; cervical adenitis, 1 case. Among the carriers, 47 developed bronchopneumonia, 22 otitis media, and 15 empyema. That is, complications developed in 36.8 percent of carriers and 6.4 per cent of clean cases; or 12.1 per cent of all cases developed bronchopneumonia, of which 34 per cent developed empyema.

During the winter of 1917-18, Camp Taylor was heavily infected with the streptococcus hemolyticus, and almost every organization had representatives in hospital that showed this organism. Of the 388 cases studied by Levy and Alexander23 at Camp Taylor, Ky., 346 were from the depot brigade, which was composed principally of troops recently arrived in camp. One company of 95 men was examined and 83.2 per cent were found to be carriers. Men composing one draft assigned to Camp Taylor were examined to demonstrate whether this high carrier rate occurred in camp or was imported. To accomplish this end, 489 new recruits were examined as they stepped from the train. The result of this examination showed that 14.8 per cent harbored the Streptococcus hemolyticus; therefore, it was concluded that the men were also acquiring the carrier state in the camp.

According to Capps,24at Camp Grant, Ill., where more than 900 cases of measles occurred during the winter 1917-18, only 20 developed bronchopneumonia, most of which were of streptococcal origin. As a primary infecting organism in the causation of respiratory infections in our home camps, the streptococcus had a formidable record; but as a secondary infection, especially in pneumonia and measles, this organism was more dangerous than all others put together.

Clendening25studied the incidence of Streptococcus hemolyticus infection in lobar pneumonia following measles and scarlet fever at Fort Sam Houston, Tex. To the base hospital there, from December 1, 1917, to March 1, 1918, 319 cases were admitted as primary lobar pneumonia, 44 of which became reinfected with the Streptococcus hemolyticus. And among 97 cases of empyema, with 32 deaths, 18 were due to the streptococcus. During this same period,


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there were 716 cases of measles, among which were about 150 cases of otitis media, 89 cases of bronchopneumonia, 12 cases of articular rheumatism, and 2 cases of meningitis with general sepsis. All were ascribed to the streptococcus. Knowlton,26 working at the base hospital, Camp Jackson, S. C., reported the results of routine throat cultures from October, 1918, to May, 1919, when measles cases were examined to determine what part the Streptococcus hemolyticus played. There were 458 cases of measles in an eight weeks' period which ended December 13, 1918. Postnasal cultures were taken in these cases. The percentage of positives varied materially in different weeks; the lowest was 19 per cent in the fourth week and the highest 45 per cent in the eighth week. The percentage also varied in different wards, the highest being in a ward where cubicles were not at first used. A special study was then made to determine what part the streptococcus played in complications. Among 458 cases of measles there were 13 deaths, or 2.7 per cent case fatality; 48 of the cases developed pneumonia, of which 10 showed empyema, with the Streptococcus hemolyticus as the predominating organism. Six deaths occurred among these empyema cases. There were 43 cases of suppurative oditis media, 5 of which developed mastoiditis. Knowlton found that pneumonia and otitis media occurred in the same proportion of patients whose throat cultures showed the streptococcus as among those whose cultures were negative. Of 458 throat cultures, 122 were positive and 336 negative. Cases with pneumonia as a complication were positive in 10.6 per cent. The cases with otitis media as a complication were positive in 9 per cent and negative in 9.8 per cent. He concluded that there was no relation between the presence of the Streptococcus hemolyticus in the throat and the occurrence of complications of measles.

In an investigation of the occurrence of the streptococcus in the throats of measles patients on admission to the hospital at Camp Pike, Ark., during September and October, 1918, the following data were obtained:27

 


Number of measles patients whose throats were swabbed

Number harboring hemolytic streptococci

Per cent harboring streptococcus

On admission

598

15

2.51

After 1 week in hospital

359

14

3.9

After 2 weeks in hospital

170

17

10.0

After 3 weeks in hospital

41

9

22

The incidence of the Streptococcus hemolyticus in the throats of patients admitted to hospital with measles was comparatively low. With progress of the disease, as measured by the length of stay in hospital, the proportion of patients harboring the streptococcus gradually increased.27

DIAGNOSIS

The diagnosis of measles is dependent upon clinical manifestations. No known serological or bacteriological findings are of diagnostic importance. These facts were known before the war, and experience gained during the war furnished nothing worthy of special mention. Although a common disease,


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and in its characteristic form readily recognized not only by physicians, but also by the laity in the vast majority of instances, there are cases where differential diagnosis is difficult and may lead to error. This undoubtedly accounts for the majority, if not all, of the so-called recurrent attacks of measles. The confusion with smallpox, so often spoken of in ancient writings, is not a matter of great concern at present, at least it did not exist in the Army during the World War.

The prodromal scarlatinal type of rash may lead to the diagnosis of scarlatina, and vice versa, when patients are admitted to hospital in this stage of measles. The diagnosis of scarlet fever may be made and later the typical clinical picture of measles may develop, thus leading not only to confusion, but also to an additional diagnosis. This in all probability, accounts for some of the cases reported as a double infection of measles complicated by scarlatina, or vice versa.

The somewhat similar nomenclature of measles and German measles is based upon clinical manifestations and not upon the etiology. These conditions are recognized as distinct and separate diseases, the points of differentiation being mentioned in the chapter on German measles. The necessity for a differentiation between these diseases is not uncommonly encountered; statistics from Camp Lewis, Wash., and possibly those from Camp Cody, N. Mex., during the last four months of 1917, indicate that medical officers on duty in those camps experienced some difficulty. During this period extensive epidemics of measles prevailed in the Army camps throughout the United States. The general health of Camp Lewis remained good during the latter months of 1917 except for an outbreak of German measles.28By December, this disease had reached epidemic proportions and 1,000 cases were reported sick during that month. Meanwhile, there was very little plain measles; however, as the epidemic of German measles died away, true measles became commoner and rose to about 200 admissions per month. Indeed, for a time in the spring of 1918, Camp Lewis had more true measles than any other camp in the United States save Camp Cody.28The significance of the apparent substitution of German measles for true measles at Camp Lewis in the early winter of 1917-18 remains unsolved. During 1917, there were 9,244 primary admissions for German measles, Camp Lewis furnished 1,548 and Camp Cody 1,351. During this time, Camp Lewis reported 164 primary admissions for measles and Camp Cody 337. In view of the extensive occurrence of measles in other Army camps and the comparatively minor occurrence of German measles, it would appear that the diagnosis of these two diseases was confused in the two camps above mentioned.

PROGNOSIS

There appears to be no reason to believe that measles per se resulted in death or permanent disability during the war. The prognosis of this disease is the prognosis of its complications. Further, measles offers favorable conditions for the development of the pneumococcus and opens the doors to the streptococcus, the organisms that were most destructive to life and left more permanent disability in their wake among soldiers than all other known germs. It is generally accepted that the death rate is higher among measles cases


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treated in hospitals than in those treated in private homes. This is due to cross infections resulting in complications that may be increased by faulty technique, faulty hospital construction for isolation, careless attendants, poor ventilation, and overcrowding in hospitals. Conditions are most favorable for fatal pneumonia epidemics in military camps when the disease appears during cold weather and when virulent pneumococci and streptococci are prevalent. These conditions existed in the fall and winter of 1917-18.

There were 2,370 deaths recorded among the primary admissions and 162 among cases in which measles was a concurrent disease. The case fatality was 2.4 per cent among the former. One hundred and forty-nine men were discharged from the Army on account of permanent disability following admission to hospital for measles. The majority of these cases suffered from disabilities directly attributable to pneumonia and its complications. More than 22,000 complications were reported among the primary admissions for measles. When viewed from this standpoint, it is seen that the prognosis was not so favorable in the Army as is generally accepted among the civil population.

PREVENTIVE MEASURES

The virus of measles is contained in the nasopharyngeal discharges and in the blood at an early stage of the disease. Thus communicability begins, certainly, before the appearance of the exanthem and in all probability before the Koplik spots; it may exist, at least to some degree, from the very beginning of the infection. Efforts to prevent spread from the respiratory system led to the system of isolation, the use of sputum cups, cubicles for patients, gowns and masks for attendants, and such terminal disinfection as was used during the World War.

Appreciating the value of immunity conferred by previous attacks for purposes of quarantine, Munson,29in 1916 caused a census to be taken at Camp Wilson, Tex., to determine from the statements of the soldiers whether or not they had previously had measles. With this information as a basis of quarantine for contacts, along with avoidance of overcrowding in tents, the sunning of bedding and personal effects, and with proper ventilation of sleeping quarters, outbreaks of measles at Camp Wilson were brought under control. Munson held that measles epidemics are preventable. He recognized that a census, based upon the soldiers' statements, is only approximately correct; however, it is sufficiently accurate for practical purposes, and the error lies largely in the direction of the soldier reporting a previous attack of measles when he really never had it.

Sellards30 reported on a census of susceptibility to measles and its relation to quarantine procedures at Camp Meade, Md. This census differed from that reported by Munson,29as the statement of each soldier was checked by a written report from his parents. Discrepancies were numerous and were almost entirely in the direction of the soldier having altogether forgotten attacks of measles that occurred in early life. To avoid prejudicing him, the soldier was given a card to complete, which showed not only measles but also scarlet fever, German measles, and meningitis. In 144 statements of soldiers claiming measles, the parents confirmed them in 133. In 89 cases where soldiers reported


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no measles the parents confirmed them in 49. This shows the greater portion, 92 per cent, of answers indicating a previous attack was confirmed by the parents, while, of those indicating that no previous attack of the disease had occurred, 55 per cent were not confirmed by statements of the parents. Sellards obtained similar results in a census at Camp Devens, Mass.31 These results introduced an element of doubt into some of the conclusions drawn by Munson, since the number of measles cases developing at Camp Wilson, Tex., was only one-fifth of the entire number reporting themselves as susceptible. Munson concluded that the preventive measures probably protected four-fifths of the supposedly susceptible men, while of the 89 men at Camp Meade reporting themselves as susceptible, more reliable information from the parents indicated susceptibility with reasonable certainty in 22, or one-fourth of the number.

A measles census was taken at Camp Pike, Ark.,32and the results attained are rather striking. It was found that 61.5 per cent of the white recruits were classified immune and 38.5 as nonimmune. Approximately 30,732 immunes furnished 44 cases of measles, or 1.4 cases per 1,000 strength, while approximately 19,261 nonimmunes furnished 956 cases of measles, or 49.6 cases per 1,000. It was reported that the infrequency of measles among the men classified as immunes had been of great assistance in the selection of men for shipment to other camps and to ports of embarkation. Although, as shown above, there was some discrepancy relative to the value of a measles census, this information, when it is practicable to obtain it, is of great value in dealing with outbreaks of the disease.

Gittings33 reported on the military value of the immunity conferred by previous attacks of measles, scarlet fever, and mumps at Camp Mills, Long Island. In the fall of 1917, both measles and German measles were epidemic at that camp; and as patients were questioned on admission to the camp hospital, it was very noticeable that those suffering from German measles almost invariably gave a history of having had a severe attack of true measles, while those with measles denied ever having had a previous attack or admitted having had it only in a mild form. So noticeable was this that it became a factor of distinct importance in determining the diagnosis in early doubtful cases and often formed the basis for isolation into one or the other groups. Subsequent developments almost invariably substantiated the history. Commenting on the value of previous attacks of measles at the United States Army General Hospital No. 9, Lakewood, N. J., Gittings stated that the observations made at Camp Mills were corroborated. These observations were based upon an analysis of 100 Hospital Corps men transferred from Camp Greenleaf, Ga. From them it was concluded that immunity conferred by previous attacks of measles, German measles, scarlet fever, and mumps should be recorded on the service record of the soldier at his first physical examination and that subsequent attacks while in the service should be recorded, as this information possesses practically the same significant value as does the record of typhoid and smallpox prophylactic vaccinations.

Previous to the World War numerous investigators attempted to produce active or passive immunity in measles. Various methods were employed and favorable results reported in some instances. In so far as passive immunity is


442

concerned, Sellards,31 working at Camp Devens, used blood from active cases of measles on two volunteers to test their susceptibility to measles. These men were exposed to a child in the preeruptive stage and were also thoroughly inoculated over the mucous membranes of the eyes, nose, and throat with mucous secretions from this patient. They developed no symptoms of the disease.

Attempts at the production of active immunity, not only against measles itself but against some of its more important complications, were attempted in the camps during the war. MacCallum,34in 1918, stated that in order to prevent the extensive occurrence of measles among the troops quarantine methods or some form of prophylactic vaccination might be feasible. Several months prior to this, it was reported from Camp Pike,35investigations were begun on a vaccine made of the Tunnicliff coccus. The original plan was to secure complete statistics on the vaccination of 2,000 men. Soon after this work began, 1,350 of the 1,500 men who had received the first inoculation were transferred to Newport News, Va., thus making complete inoculations and observations impossible. These were casual troops and had repeatedly been exposed to measles. Four cases developed among the 1,350 men who had received the inoculation, and 16 cases developed among 1,500 others in the same depot who had not been vaccinated. Following the above-mentioned transfer, 500 men were given the first and second inoculations seven days apart. Two cases of measles developed among them between these inoculations. During the same period 15 cases developed among uninoculated troops. Before a third inoculation could be accomplished all but 146 were transferred. The 146 received a third inoculation and, in so far as was known, none developed measles. At the conclusion of these observations, 176 men had received the third injection. Among these there were 2 cases of measles. The experiments were not considered complete or conclusive, but it was the impression that the vaccine produced some immunity, and pneumonia, as a complication, seemed to have been less common.35

Coincidentally with attempts to treat measles at Camp Gordon, Ga., it occurred to the chief of the medical service there36 that it would be advisable, on account of the dangerous complications, to make some attempt to immunize measles cases against streptococcus infection. A vaccine was prepared with this in view, using various strains of streptococci obtained from the pleural cavity, heart's blood, lung, pertioneum, and cases of empyema. A series of 100 measles cases was used for these observations, 50 receiving the vaccine and 50 being used as a control. The vaccinated cases were given three injections at five-day intervals. Both test and control cases were kept under identical conditions. Of the 50 cases so vaccinated, 2 developed streptococcus bronchopneumonia, and of the 50 control cases, 14 developed streptococcus bronchopneumonia or empyema. These results were considered sufficiently satisfactory to warrant its continuance at Camp Gordon, and conclusions were drawn that while there were from time to time cases of streptococcic empyema and pneumonia following measles, the condition no longer presented the menace to life and health which it had during the winter months.

Munson,29in 1916, reported the prevention of measles at San Antonio, Tex., by requiring frequent medical examinations; the isolation of all suspects


443

until a definite diagnosis could be made and of susceptible contacts for 14 days; the establishment of sanitary regulations to prevent the transmission of the virus from soldier to soldier; the regulation of places of amusement and recreation; the furling of tents to expose bedding and clothing habitually to the sun and air for at least two hours daily; the prohibition of the common drinking cup and of the practice of spitting in the barracks; the use of the measles census. All of these methods were employed during the war, but without accomplishing the results reported by Munson.

As previously stated, during the fall of 1917 incoming troops were assigned directly to organizations without a period of detention.7As soon as practicable incoming troops were assigned to organizations or placed in separate detachments, quarantined with the organization but in separate barracks for a period of 14 days. Daily examinations were made for the detection of contagious diseases during that period. After the first 32 divisions had been organized, incoming troops were assigned to a separate organization, the depot brigade which, at times, aggregated more than 10,000 men per camp.7Segregation was attempted in the depot brigade as far as sleeping quarters, mess, and drill were concerned. In some instances, troops were held in more or less effective quarantine for the expiration of two weeks, but generally speaking they intermingled with other members of the camp during recreation and amusement. This method was an improvement over the assignment direct of incoming troops to permanent organizations; but the depot brigade existed for the purpose of preliminary training for and supplying troops to the division of the camp of which it was a part, and the prevention of the spread of the contagious diseases was not its prime function.

In the summer of 1918, detention camps were authorized for the large cantonments.37It was contemplated that all incoming troops would first pass through these detention camps where contagious diseases would be detected, patients isolated, and the command thus kept reasonably free. The armistice was signed before these detention camps were completed.

In some camps a rapid examination of incoming men was made at the railroad station and suspicious cases were segregated.7Quarantine was operated in some, by organizations in which measles occurred. In some instances whole companies were quarantined for 14 days; however, in most instances only immediate contacts were quarantined. Where a command was known to be infected, daily examinations of the entire command were made by medical officers, throats sprayed, and precautions taken to provide good ventilation and the best feasible separation of men at night.7Cubicles were installed in some barracks, use being made of the shelter half as the means of separating adjacent beds; special local regulations were issued against spitting, and soldiers were cautioned against the dangers of coughing and sneezing while in the vicinity of others; alternate head and foot sleeping was ordered and enforced during the latter part of the war.7Dust from roads and walks was looked upon as a predisposing cause, not only in measles, but also in other infectious diseases; hence roads were sprayed with oil in some camps, with apparently good results in the southwestern camps.7

The proper heating and ventilating of barracks were given serious consideration. Heating was difficult, particularly in the fall of 1917, as many of


444

the heating systems were incomplete.7Many of the barrack buildings were heated with stoves and soldiers habitually congregated around them, thus increasing the dangers of droplet infection. Orders were issued in an attempt to prevent this.7With inadequate heat it was difficult and at times impossible to enforce regulations for ventilation, so night inspections were commonly made by company and regimental medical officers to enforce this order.7

Contact with civilians was thought by some medical officers to be a cause of introducing measles into camp. However, in the American Expeditionary Forces, Emerson10 found no evidence that infection was transmitted from the civilian population to members of the American Expeditionary Forces; no epidemics occurred after the armistice began, and most of the cases that did occur were reported from the armies in the advance section. Many medical officers felt that, owing to the ease with which the infectious agent of measles could be transmitted from person to person and to the high susceptibility of the nonimmune, any real effort to prevent the infection was more or less futile.10

In general, upon the detection of measles the patient was sent by ambulance to the hospital for segregation, observation, and treatment.7In the early part of the war, little or no attention was paid to the possible spread of infection while en route to hospital, although these patients at times were dispatched in the same ambulance with others. After the use of the face mask at Camp Grant, Ill., in the fall of 191738 was reported, this means of preventing the spread of infection was applied to patients in the regimental infirmaries and in ambulances. An order was issued that all patients suspected of having an affection of a respiratory nature should be masked until arrival in the proper ward at the hospital.39As the war progressed and more experience was acquired, every effort was made to prevent the spread of infection from the time the patient was detected until arrival at his bed.

It has been the practice in military as well as in civil hospitals to segregate patients with measles from those suffering from other diseases. This was the aim during the war; however, the vast majority of cases were received at the military hospitals during the second stage of the disease and had had ample opportunity to spread the virus to others before arriving at the receiving ward. Once received, they were placed in specially designated wards, where the attendants wore gowns and masks, and where sputum cups, special dishes, and thermometers were provided for these patients.40 The linen was sent to disinfectors as soon as these appliances became available. In October, 1917, the base hospital, Camp Grant, Ill., in an effort to prevent droplet infection, established the plan of masking measles patients and isolating them by means of cubicles, formed by sheets suspended on transverse and longitudinal wires stretched across the ward.41 As stated above, these preventive measures were received with favor and soon adopted throughout the Army.40The paper sputum cup was later supplemented by the paper bag and paper napkin as receptacles for nasal discharges. These were collected at regular intervals and burned. It was realized that separate rooms would be better than wards for measles patients but this was not possible on account of the number of cases. Such practice would also have called for considerable additional personnel, which was not available. In fact, the hospitals were not constructed with any such practice in view.


445

During the latter part of 1917, the problem that confronted the hospital was the actual care of measles in its acute stages. In December, this problem became more difficult on account of the pulmonary complications-principally pneumonia of the pneumococcus type. In the early part of 1918, the type of pneumonia, generally speaking, became the streptococcus type, many cases of which were followed by empyema. It was realized that measles infection lowers the resistance and predisposes the individual to a great variety of other infections and that the mortality depends largely on the occurrence of secondary infections which accompany or follow the primary disease. The attention of medical officers in the field, therefore, was directed to the prevention of these secondary infections.40

Inasmuch as base hospitals could control the patients only from the time they were received in the hospital, the success of isolation depended on the percentage of secondary infections acquired after their admission. Levy and Alexander23 recommended that all new measles patients be held in segregation until identified as clean cases or carriers and then be assigned to wards accordingly. In one ward with 15 clean cases quartered with 15 contaminated cases, it was found, at the end of one week, that only 6 noncarriers remained. In another ward of 24 patients, of whom 12 were carriers, only 3 remained clean at the end of a week. Thus they showed that clean cases became contaminated when the ward was mixed. During another observation it was found that where proper segregation was maintained, strictly clean wards remained clean. They concluded that if the incidence of complications in measles is to be reduced, carriers must be separated and cared for in different wards. Lynch and Cumming42 believed that the air-borne or respiratory diseases are essentially hand-to-mouth infections and that measures applied to prevent this will enormously reduce their occurrence. Friedman and Vaughan43 remarked that in considering the prevention of measles complications, while emphasis was rightly laid on direct transmission through droplet infection, the indirect means through attendants, utensils, etc., was being unduly neglected. They recommended cubicles of a more substantial nature than sheets: A wooden frame 8 feet long, 6½ feet high, with a sheet or canvas tacked across it. This device rested on 18-inch bases and was placed between adjacent beds. Further, these authors treated cases at Camp Sevier, S. C., as bed patients until considered safe as to carriers by the ward surgeon. A gown was permanently kept in each cubicle and worn by every individual who entered. Individual thermometers, wash cloths, basins, towels, and glasses were kept in each cubicle. The dishes were soaked in lye solutions and then washed in hot water; bed pans and urinals were washed in water immediately after being used and then placed in large galvanized iron cans containing lye solution; medicine glasses, syringes, and ice bags were sterilized after use; the water taps and basins in the bathrooms were washed with lye solution. The number of cases reported by these authors is too small to base definite conclusions on; however, the above mentioned technique would be difficult to carry out in military hospitals and would require considerable additional equipment and personnel. Nevertheless, vigilance and discipline can do much toward controlling measles.

Clendening's25 plan was to segregate every case of pneumonia, measles, and scarlet fever for 24 hours, during which time throat cultures were made


446

and examined. The disposition of the case then was determined upon by whether or not the streptococcus was present. It was claimed that the incidence of bronchopneumonia was greatly reduced by this method.

In many, if not in all, of the camps the Streptococcus hemolyticus was found associated with many cases of pneumonia that complicated measles; it also occurred to a variable extent independently. This organism was found in the throats of patients suffering from measles and in contacts, as well as in the throats of soldiers chosen at random. Whether it was brought by carriers or disseminated through the camp can not be stated; however, there are reasons to believe that such diseases as measles and influenza and the time of year, such as the winter season, played an important part. Otherwise there would have been outbreaks of pneumonia due to this organism as soon as the troops reached camp, which was not the case.44In addition, there would have been no such clear connection between the measles curve and the pneumonia curve as was the case. Further, the principal outbreaks of pneumonia would not have developed in winter and would not have terminated abruptly in the spring.

The camp epidemiologist, Camp Pike, Ark., in a special report on measles at that place, stated that owing to the crowded condition in the base hospital during the fall of 1917 measles cases were treated in barracks set aside for that purpose in each organization area.45This report was based upon the comparative results between 538 cases treated in the base hospital and 256 treated in barracks. Among the former, 51 developed complications, of which 30 were pneumonia, with 11 deaths. Among the latter, 4 developed complications, 2 of which were pneumonia; in addition, there was 1 death following the complication of otitis media. In other words, 9.5 per cent of the hospital cases and 1.6 per cent among those in barracks were complicated by other diseases. The death rate among the former was 2 per cent and among the latter 0.4 per cent. These figures are small but significant. The essential differences in the care of these cases were: More space afforded cases treated in barracks than in hospital; the liability to cross infection was greatly reduced among the barracks cases, though nursing facilities were practically nil there, with the exception of orderlies to care for the food and excretions of the patient.

When patients are out of bed and able to go about the ward, when they come in close contact with others, the danger of the transfer of measles has passed. However, the danger of transfer of secondary infecting agents often is still present. The danger of spreading secondary infection during convalescence may be removed, to a great extent, by wearing gauze masks over the mouth and nose. This became a common practice after the dangers of cross infection were more fully recognized.

During the major portion of the first year of our participation in the war, the men were sent to duty when the temperature had returned to normal, desquamation was completed, and the physical condition was apparently good. The duration of hospitalization in many instances was also abbreviated as far as possible on account of the urgent need for additional beds. This practice led observers to believe that complications occurred and that patients were sent to duty before their physical condition justified it. As a result, the Surgeon General issued instructions that all convalescent measles patients would be held


447

in hospital, or under observation, for at least two weeks after the temperature had returned to normal.40 Although there are no statistics available to show the value of this order, it is the consensus of opinion of medical officers that it measurably reduced the number of complications and deaths.

Room disinfection following measles was not a routine practice in the Army even at the outbreak of the war. It was used in isolated cases, but, in so far as the records show, it fell into disuse as being of no value. The larger hospitals were provided with steam disinfectors for the sterilization of wearing apparel and bedding.46These appliances had a capacity of 30 to 40 mattresses. Pillows, blankets, and mattresses were disinfected, at times, after measles, but not as a routine.7The general practice was to send them to the disinfector when they were macroscopically soiled. Linen from the contagious services was run through the disinfector before being sent to the laundry, when time and opportunity were available. In isolated instances, following outbreaks of measles, regimental surgeons sent the blankets and mattresses of entire companies or detachments to the hospital for disinfection.7This, too, was not a routine practice, and there is nothing in the records to indicate that it had any influence in controlling the disease.

While the measles virus is short-lived outside of the body and is killed readily by exposure to sun and air, this is not true to the same degree of organisms causing secondary infections. Bacteria causing the latter may retain their vitality and pathogenicity for a long period after mucus secretions which contain them have dried. It was along these lines that terminal disinfection, as applied to bedding, linen, floors, and mess equipment was considered of special value.

TREATMENT

The general care of measles patients during the World War was that of other infectious diseases. The uncomplicated case required no special treatment. The treatment of measles carried out in the base hospital at Camp Jackson, which may be taken as the usual treatment used throughout the Army, follows:47

There were no striking developments in the treatment of measles during the war. Various methods were employed in attempts to minimize complications, but none of them was conspicuously successful, and until the causative agent is identified and a potent protective serum developed, there is little hope there will be any brilliant progress in treatment. In general, treatment was directed toward keeping patients as comfortable as might be, supporting the strength, aiding elimination, and an effort to prevent intercurrent respiratory complications. Many different methods to these ends were employed and the details varied somewhat in each hospital, and at times in each ward. However, disturbing patients to administer some drug which, theoretically, would prevent some possible complication or be given as a placebo was not justified by the results obtained. Procedures which promised well during the early trials were found valueless when given the test on a larger series of cases.

The treatment at Camp Jackson which seemed to give most comfort to the patient was briefly as follows:47

The wards were kept well ventilated but not allowed to become cold, as cold air always increased the amount of coughing. It was not necessary to darken the wards; however, patients were shielded from direct sunlight and those with marked photophobia were removed to the darker parts of the ward. Artificial lights were carefully shaded and patients with annoying cough were grouped, as far as possible, at one end of the ward to minimize the


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disturbance that they caused to others. Laxatives were given routinely on admission and aspirin for headache if necessary. Patients were encouraged to drink water freely. The diet was found to be practically self-regulating, and during the period of high temperature there was little or no desire for food, so liquids were practically the only form of nourishment taken. If vomiting developed, all food was withheld until it ceased, which usually occurred in 24 hours. There was much less nausea among patients so treated than among those given food during the period of nausea, and the period of starvation was so short that it did not impair the patient's strength. When nausea ceased, the patient was then allowed a general diet. Mastication aided in keeping the mouth and tongue clean and stimulated gastric digestion; liquids and soft diets all tasted alike to the patient with a foul mouth, while solid foods well seasoned were apt to be fairly palatable and when taken in larger amounts maintained nutrition at a higher level. This point was important to a patient facing the possibility of pneumonia, or some other serious disease, as a late complication. Not only was his resistance to infection greater, but his recuperative power, if infection occurs, was superior to that of an undernourished individual.

Cough was often a troublesome symptom, preventing sleep alike to the individual and his neighbors. Cold air greatly aggravated it, as shown by the amount of coughing at night compared with the day. It was often the custom to open ward windows at night, with a distinct lowering of the room temperature and increase in the amount of coughing. To keep the ward warm at night as well as in the day lessened cough demonstrably. For the measles patient whose cough is due to inflammation of the upper respiratory passages, warm air is a necessity. When cough was not controlled by temperature and moisture of the room, opium was used either in the form of codein by mouth or morphia hypodermically.

As stated above, many attempts were made to prevent the development of upper respiratory complications. Germicidal solutions were used as a spray without success, patients washed their mouths and gargled with a bland alkaline solution twice daily when they brushed their teeth, vaseline containing some menthol was used for local discomfort in the nose, while liquid albolene was used if the mouth was sufficiently dry to cause discomfort. There was nothing to indicate that spraying was of value and the other forms of treatment enumerated were entirely symptomatic. Special attention was paid to the detection of complications in their early stages, and when detected the treatment was that of the complication in question. Otitis media, especially if due to the Streptococcus hemolyticus, developed with surprising rapidity, and rupture of the drum membrane was observed at times in a few hours after the onset of pain. Early paracentesis was necessary for treatment and the prevention of mastoid involvement. Meningitis appeared to assume its most fulminating form when it developed during measles.

It was recognized early during the war that measles patients who developed pneumonia should be isolated in wards specially designated for that purpose, as they were a potential source of infection for others. Therefore measles pneumonias were cared for separately and not allowed to remain with uncomplicated measles or cared for in wards where primary lobar pneumonia or bronchopneumonia cases were. Some camps, as a routine, examined all measles admissions for streptococcus in throat smears, and when found the patients were assigned to separate wards.


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Treatment of the carrier state (streptococcus) was disappointing. Levy and Alexander23reported that throat cultures made at intervals in many of the "dirty" wards showed that the carrier state, once acquired, persisted throughout the patient's stay in hospital and exceptions to this rule were rare. Attempts were made at mouth disinfection without success. Neutral solutions of chlorinated soda in half strength, which had been in common use as a gargle and spray in many Army hospitals, will not kill the Streptococcus hemolyticus even in vitro; while experiments with other mouth antiseptics, notably iodine in glycerin, though successful in the test tube, were clinically disappointing. Of the patients discharged from the hospital at Camp Taylor, who during their stay in the institution were proven to be carriers of the streptococcus, 71.7 per cent, in spite of treatment, still harbored the organism upon return to duty.

REFERENCES

(1) Based on Annual Reports of the Surgeon General, U. S. Army for the years 1840-1920.

(2) The Medical and Surgical History of the War of the Rebellion, Medical Volume, Part Third, 649. Government Printing Office, Washington, D. C.

(3) Annual Report of the Surgeon General, U. S. Army, 1866.

(4) Annual Reports of the Surgeon General, U. S. Army, 1867-1898, inclusive.

(5) Annual Reports of the Surgeon General, U. S. Army, 1899-1916, inclusive.

(6) Annual Report of the Surgeon General, U. S. Army, 1912.

(7) Based on reports of general sanitary inspectors. On file, Record Room, S. G. O., 721-1.

(8) Duncan, Louis C.: An Epidemic of Measles and Pneumonia in the 31st Division, Camp Wheeler, Ga. The Military Surgeon, Washington, 1918, xlii, No. 2, 123.

(9) Histories of base hospitals in the United States. On file, Historical Division, S. G. O.

(10) Emerson, Haven: General Survey of Communicable Diseases in the A. E. F. The Military Surgeon, Washington, 1921, xlix, No. 4, 398.

(11) Report of the Chief of the Construction Division, 1919.

(12) Hackett, F. J.: Measles from the Standpoint of Military Medicine. Medical Record, New York, 1918, xciii, No. 11, 475.

(13) Personal observations.

(14) Hamburger, W. W. and Fox, H.: A Study of the Epidemics of Pneumococcus and Streptococcus Infections, and Measles, at Camp Zachary Taylor, Ky., Autumn, 1917, to Summer, 1918. On file, Historical Division, S. G. O.

(15) Francine, A. P.: A Statistical Review of the Pulmonary and Cardiovascular Defects Found in the 82d Division, U. S. National Army, Camp Gordon, Ga., with a Report of After-Results in 500 Measles Cases. The Military Surgeon, Washington, 1918, xliii, No. 2, 160.

(16) Berghoff, R. S.: Measles a Predisposing Factor Toward Pulmonary Tuberculosis. Illinois Medical Journal, Chicago, 1919, xxxv, No. 2, 62.

(17) Sellards, A. W., and Strum, Ernest: The Occurrence of the Pfeiffer Bacillus in Measles. Johns Hopkins Hospital Bulletin, 1919, xxx, No. 345, 331.

(18) Vaughan, Victor C.: Epidemiology and Public Health, Volume I, Respiratory Infections, C. V. Mosby Co., St. Louis, 1922, 159.

(19) Irons, E. E., and Marine, D.: Streptococcal Infections Following Measles and Other Diseases. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 10, 687.

(20) Cole, Rufus, and MacCallumn, W. G.: Pneumonia at a Base Hospital. The Journal of theAmerican Medical Association, Chicago, 1918, lxx, No. 15, 1146.

(21) Hektoen, Ludwig: The Bacteriology of Measles. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1201.

(22) Cumming, J. G.; Spruit, C. B.; and Lynch, Charles: The Pneumonias: Streptococcus and Pneumococcus Groups. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 15, 1066.


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(23) Levy, R. L., and Alexander, H. L.: The Predisposition of Streptococcus Carriers to the Complications of Measles. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 24, 1827.

(24) Capps, Joseph A.: The Limitation and Control of Streptococcus and Other Respiratory Infections. War Medicine, Paris, 1918, ii, No. 4, 571.

(25) Clendening, L.: Reinfection with Streptococcus Hemolyticus in Lobar Pneumonia, Measles, and Scarlet Fever and Its Prevention. American Journal of the MedicalSciences, Philadelphia, 1918, n. s., clvi, 575.

(26) Knowlton, R. H.: Report of Throat Cultures in Measles, The Journal of the American Medical Association, 1919, lxxii, No. 21, 1524.

(27) Letter from Lieut.-Col. Eugene L. Opie, M. C., to the Surgeon General, October 31, 1918. Subject: Investigation of pneumonia and measles at Camp Pike. On file, Historical Division, S. G. O.

(28) Annual Report of the Surgeon General, U. S. Army, 1918, 169.

(29) Munson, Edward L.: An Epidemiological Study of an Outbreak of Measles, Camp Wilson, Tex. The Military Surgeon, Washington, 1917, xl, No. 6, 666, to xli, No. 3, 257.

(30) Sellards, A. W.: A Census of Susceptibility to Measles and its Relation to Quarantine Procedures. The Military Surgeon, Washington, 1919, xlv, No. 5, 562.

(31) Sellards, A. W.: Insusceptibility of Man to Inoculation with Blood from Measles Patients. The Johns Hopkins Hospital Bulletin, Baltimore, 1919, xxx, No. 343, 257.

(32) Memorandum from Col. W. P. Chamberlain, M. C., to Col. Deane C. Howard, M. C., Office of the Surgeon General, November 15, 1918. Subject: Medical inspection at Camp Pike, Ark. On file, Historical Division, S. G. O.

(33) Gittings, Jack C.: Observations on the Military Value of the Immunity Conferred by Previous Attacks of Measles, Scarlet Fever and Mumps. The Military Surgeon, Washington, 1919, xliv, No. 6, 640.

(34) Letter from Contract Surgeon W. G. MacCallum, U. S. Army, to the Surgeon General, September 6, 1918. Subject: Experimental study of measles. On file, Historical Division, S. G. O.

(35) Letter from Maj. E. F. McCampbell, M. R. C., Camp Pike, Ark., to Col. F. F. Russell, M. C., June 2, 1918. Subject: Measles vaccine. On file, Historical Division, S. G. O.

(36) History of Base Hospital, Camp Wheeler, Ga. On file, Historical Division, S. G. O.

(37) Memorandum from the Assistant Chief of Staff, Director of Operations, to the Assistant Secretary of War, August 20, 1918. Subject: Additional construction in National Army and National Guards camps. (Approval of Secretary of War affixed thereto.) On file, Record Room, S. G. O., Correspondence File 632 (General).

(38) Capps, J. A.: A New Adaptation of the Face Mask in Control of Contagious Disease. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13, 910.

(39) Circular Letter No. 1, Surgeon General's Office, March 25, 1918.

(40) Circular memorandum from the Surgeon General, January 1, 1918.

(41) History, Base Hospital, Camp Grant, Ill., by Lieut. Col. H. C. Michie, M. C., commanding officer. On file, Historical Division, S. G. O.

(42) Lynch, Charles, and Cumming, J. G.: The Rôle of the Hand in the Distribution of the Influenza Virus and the Secondary Invaders. The Military Surgeon, Washington, 1918, xlii, 597.

(43) Friedman, J. C., and Vaughan, W. T.: Comments on the Methods Employed in Preventing Measles Complications. The Medical Clinics of North America, Philadelphia, 1911, ii, No. 2, 559.

(44) Memorandum by Maj. John Howland, M. R. C., U. S. Army, Office of the Surgeon General, Washington, August 13, 1918. On file, Historical Division, S. G. O.

(45) Letter from the camp epidemiologist to the camp surgeon, Camp Pike, Ark., January 3, 1919. Subject: Special report on measles during September, October, and November, 1918. On file, Historical Division, S. G. O.

(46) Based on plans for base hospitals. On file, Historical Division, S. G. O.

(47) Memorandum on measles by Maj. Charles H. Lawrence, M. C., U. S. Army. On file, Historical Division, S. G. O.