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 adisease which gives relatively little concern to the medical department of anarmy; most troops, under such circumstances, having had some years of service,either have had the disease and thus developed an immunity to it, or, havingbeen exposed, have escaped the disease by reason of the fact that they alreadypossessed an immunity. Therefore, during peace times, measles usually has beenlimited, in so far as serious outbreaks in the Army are concerned, to recruitdepots. On the other hand, when the Army has been greatly expanded, as inmobilization for war, the incidence of measles greatly increased. Thus measleshas played a very important part during the various wars in which the UnitedStates Army has participated.
Chart XLIV has been prepared to show the incidence of measlesin the Army for the period 1840-1919.1 Prior tothe Civil War, the Army had no colored enlisted men, so figures for whiteenlisted men only have been used to make the ratios comparable. This chart showsmeasles increased tremendously with mobilization of the Union Forces for theCivil War. During the years covered by the Civil War statistics, 67,763 caseswere reported, with 4,246 deaths among white troops, with a case fatality of6.27 per cent. Only a small part of this mortality was directly referable tomeasles;2 in many of the regiments only onedeath was caused by its epidemic occurrence. Since most of the mortality was theresult of secondary pulmonary affections, the rate given does not adequatelyexpress the situation, for many deaths were charged to the pneumonic lesionwithout 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. Althoughcertain of the intervening years were marked by distinct increases, yet theannual admission ratio did not exceed 9 per thousand except during the year of1896, when it became 10.30.4 In 1898, theadmission 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 thePhilippine insurrection (1902) and 1916, serious outbreaks of measles werelimited almost entirely to our recruit depots. Thus, during 1911, a severeepidemic, with a 5 per cent mortality, occurred at Columbus Barracks,Ohio.6Of the 1,101 cases, with 25deaths, in the total Army in the United States in 1911, 392 cases with 18deaths 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.
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On a small scale, conditions as they existed at ColumbusBarracks during the time mentioned are illustrative of what occurred in some ofthe camps during mobilization for the World War; that is, recruits from allsections of the country were crowded into barracks, and among them were men fromrural districts where there was a large percentage of measles nonimmunes. Withovercrowding, particularly during the colder months of the year, epidemicsinevitably occurred.
In greater detail, the comparative trends of cases and deathsfor the Civil War, the Spanish-American War and Philippine insurrection, and theWorld War are graphically shown in Chart XLV, by months of occurrence for whiteand colored enlisted men. From this illustration it is seen that the peak ofadmissions occurred in the early period of the respective wars. For the WorldWar, the peak occurred in November, 1917, and subsequent to that time there wasa well-marked decline in the admission ratio. During the Civil War, the peak foradmissions was reached during the first year, namely, in December, 1861. Thepeak was also reached early in the Spanish-American War. Since this war waswaged during the summer season, measles and its complications did not become animportant epidemiological problem. For the World War, the peak, taken by thedeath rate trend, also was reached in November, 1917. This was not the case inthe Civil War, as the peak did not occur until March, 1864. During the secondand third winters of the Civil War the death rate rose out of proportion to thenumber of cases reported. This may be accounted for by improvement in diagnosisduring the latter period of the war and in cases being actually charged tomeasles rather than to its pulmonary complications. The increased death rate maybe accounted for by the enlistment of colored troops after July, 1863, as theyhad higher death rates due to pulmonary complications
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The number of deaths was not great following measles duringthe Spanish-American War and Philippine insurrection. The peak, as shown onChart XLV, was reached in March, 1902.
The admission rate for white and colored troops combined forthe entire period of the Civil War, from May, 1861, to June, 1866, was 32.22 perthousand per annum; the death rate was 2.02. During the Spanish-American War andPhilippine insurrection, from May, 1898, through June, 1902, the admission anddeath ratios per thousand strength were 26.06 and 0.32, respectively. For theWorld War, based on occurrence in the United States and Europe only and fromApril, 1917, to and including December, 1919, the admission ratio was 25.28 anddeath ratio 0.63 per thousand per annum. It may be inferred, then, that measleswas better controlled during the period of the World War as a whole than duringthe other two wars under consideration, and while the death rate was twice ashigh as that for the Spanish-American War and Philippine insurrection, it wasless 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 primaryadmissions. For the total Army the admission, death, and noneffective ratioswere 23.79, 0.57, and 1.25 per thousand per annum, respectively. Americanofficers and enlisted men contributed 96,817 admissions, 2,367 deaths, and aloss of time from duty amounting to 1,864,477 days. This occurrence was amongthe total mean annual strength of approximately 4,000,000 men. Officers, asshown in Table 65, with an aggregate strength of 206,382, contributed 974admissions 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 deathratios were, respectively, 4.72 and 0.01 per thousand, the lowest in the Armywhere large bodies of troops were concerned. This is probably accounted for bythe difference in age and living conditions among officers as compared withenlisted 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 perthousand strength, respectively, and the loss of some 1,800,000 days, with anoneffective ratio of 1.31 is credited to them. Enlisted native troops, servingin their home territory, had 1,408 primary admissions among a total of a meanannual strength amounting to 36,022. There were three deaths with admission anddeath ratios of 39.08 and 0.08 per thousand per annum, respectively. From theabove it is seen that the highest admission ratios were among native troops, andthe lowest among American officers.
It was the opinion of medical officers that deaths did notfollow uncomplicated measles, but were due to complications and concurrentdiseases. It was the practice in the statistical division of the Surgeon General'sOffice, as noted elsewhere (p. 5), to charge all subsequent developments to theprimary cause of admission to sick report. This accounts for the deaths,permanent disability, and much of the time lost from duty credited to measles inthis chapter. Therefore, for a comprehensive understanding of this chapter thereader should take the method of computation into consideration.
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TABLE 65.-Measles. Admissions, deaths,discharges for disability, and days lost, by countries of occurrence, officersand enlisted men, United States Army, April 1, 1917, to December 31, 1919.Absolute numbers and rates per 1,000
| Total mean annual strengths |
| 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: |
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| 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: |
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| 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: |
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| 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: |
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| 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: |
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| 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: |
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| 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: |
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| 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: |
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| 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 notavailable.
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OCCURRENCE IN THE UNITED STATES
More than eight-tenths of the primary admissions were amongtroops serving in the United States. (See Table 65.) There were 85,398 suchadmissions among the troops serving at home and in Alaska. In so far as Alaskais concerned, for all practical purposes the number of measles admissions therewas so small it need not be considered. The total annual mean strength of theArmy in the United States was about two and a quarter million men, and amongthese there were 1,987 deaths. The admission and death ratios were 38.20 and0.89 per thousand per annum, respectively. The loss of time from duty wasconsiderable and amounted to 1,600,798 days, with a noneffective ratio of 1.96per thousand. Enlisted men serving in home territory contributed 145 of the 149cases discharged for disability. There were 84,585 primary admissions formeasles among enlisted men, 80,546 of which were among white enlisted men. Theannual 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 whichthey served. Of the total 2,370 deaths charged to primary admissions, 1,986occurred among the enlisted men serving at home. The death ratio was 0.94 perthousand. One and a half million days were lost from duty, with the highestnoneffective ratio that occurred among American troops serving in any countryduring the World War. It was 2.07 per thousand strength.
RELATION OF OCCURRENCE TO MOBILIZATION
Apparently no disease was more closely allied to mobilizationthan was measles. This is shown quite clearly in Chart XLVI. During the fall andearly winter of 1917, when mobilization camps were being organized, barracks andtents were overcrowded and inadequately heated, and it was impossible to supplythe men with sufficient warm clothing.7Theseadverse conditions were augmented by an unusually early and severe winter. Thedraft brought large numbers of persons together from all walks of life and fromevery environment. The inducted men were principally young adults and includednot only the generally immune city boy, but also vast numbers of rural lads whohad never before been exposed to the infection.
The influence of introducing large numbers of nonimmunes intothe camps during the war is shown by Chart XLVI, which depicts the comparativetrend between mobilization and measles. In November, 1918, the drafting of menceased 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 inthe Army below the 1917 peak were the better housing, clothing, isolation, andheating facilities which became available in 1918. The occurrence, however, rangenerally parallel with mobilization. Length of service also, influencedoccurrence; 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 campservice of the recruit.
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OCCURRENCE BY CAMPS
Analysis by camps of occurrence in the United States showsgreat difference in extent to which this disease prevailed. It varied from 1.19per thousand strength at Camp Syracuse, N. Y., and 7.27 at Camp Dix, N. J., to164.67 per thousand at Camp Pike, Ark., among white enlisted men. (Table 66.)The location of the camp played no determining r?le; it was largely a matter of one camp drawing a higher percentage of immunes or nonimmunes thananother. The maximum occurrence was attributed to troops from the southeasternportion of the country (Chart XLVII). From a study of the population of theeastern portion of the United States, one is justified in saying that thenortheastern section is thickly settled while the southeastern is sparselysettled. In other words, the bulk of the population in the former have lived incities and
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in close proximity, and as such may be classified as urban. In the latter, orsoutheastern portion, there are some large cities, but the bulk of thepopulation may be called rural. A large proportion of the inhabitants in urbanStates have contracted measles in childhood, while in rural States a largepercentage have not been exposed to the disease. Applying this information indiscussing 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 SoutheasternStates, namely, Alabama, Arkansas, Louisiana, Mississippi, and Tennessee. CampBowie, Tex., which stands second, drew its quota from Arkansas, Louisiana, andTexas. Camp Sevier, S. C., standing third, drew from Alabama, Kentucky, NorthCarolina, and South Carolina. Camp Wheeler, Ga., fourth on the list, drew itsquota from Alabama, Florida, Georgia, Louisiana, and Mississippi. On the otherhand, Camp Grant, Ill., which drew its quota principally from Illinois, and CampDix, N. J., which drew principally from New York and New Jersey, stand at ornear the bottom of the list of camps. The last three States are thickly settledand 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 formost of the epidemic diseases, comes Camp Travis, Tex. Camp Pike had 6,730 suchadmissions for measles among white, and 314 among colored, enlisted men. CampTravis had 4,484 among whites and 337 among colored. Camp Pike also heads thelist 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 thehighest death rate for the period, as shown in Table 66.
From the figures given above it is seen that measles was offar greater importance among white than among colored enlisted men. Thecomparative occurrence in the two races is illustrated in Chart XLIX, whichshows admissions, deaths, case fatality, noneffectiveness, days lost, anddischarges for disability among white and colored enlisted men serving in theUnited States. The admission and death ratios, as well as noneffective ratio anddischarges for disability, were greater among white than colored enlisted men.The case fatality and average days lost per case were greater for colored thanfor white enlisted men.
From the standpoint of epidemiology, the six months periodcommencing October 1, 1917, marks the measles period for the Army. During thistime there were 51,022 primary admissions among white enlisted men, and 1,487among colored, making a total of 52,509, or more than one-half of the totaladmissions for the entire Army serving in all countries.
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The occurrence of measles at Camp Wheeler, Ga., may be takenas typical of camp occurrence.8 The construction of the camp was notconcluded until November, 1917. The first troops arrived on September 5, and bySeptember 20 practically all of the National Guard troops of the division hadarrived, totaling some 11,000 men. Of these, probably 3,000 were recruits ofabout three months' service. (Measles had been occurring in the regimentssince the time of their muster in June, 1916, and most of the regiments hadexperienced considerable epidemics of both measles and pneumonia on the Mexicanborder during the winter of 1916-17; the Alabama troops had especially sufferedat 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 tocome, until by October 28, over 10,000 had arrived. These inducted men broughtmeasles on every train; cases were taken from trains where they had been shut upfor from a few hours to 24 hours or more in closed cars filled with men. It canscarcely be wondered that measles got out of control among these men and amongthe recruits of the various regiments. The number of admissions which had been 7on October 19, rose to 14 on October 21, 44 on the 23d, 70 on November 2, 102 onthe 5th, 118 on the 7th, and reached its maximum with 174 admissions on November22. By December 7, the conflagration had burned entirely out. There wereapproximately 3,000 cases among the 10,000 drafted men. It seemed that therewere about 30 per cent of nonimmunes.
The following observations were obtained from the respectivehistories of base hospitals throughout the United States.9
At Camp Custer, Mich., admissions for measles increased innumbers from the beginning of mobilization; however, the cases were very mild incharacter 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 anear-by State. Many of these soldiers were suffering from severe upperrespiratory tract infections which included laryngitis, bronchitis, andpneumonia. More than 300 cases were brought to hospital within a few days. Thedisease, however, was not confined to the new men, but soon spread to others incamp, and the measles cases, which formerly had been mild in character, nowbecame severe and marked the beginning of an epidemic of empyema. It was inJanuary, 1918, that the measles incidence began to assume epidemic proportions.
At Camp Dodge, Iowa, the incidence of measles was associatedinvariably with an increase in the strength of the command. The weather is saidto have played no causative r?le here, as it did in other camps. The highincidence was dependent upon the arrival of new troops, the percentage ofsusceptibles, possible delay in diagnosis, and cross infections in the basehospital.
Camp Fremont, Calif., reported two epidemics of measles, onelate in 1917 and the other in February and March of 1918, neither of which wasserious, and only an occasional case of pneumonia as a complication.
In the month of December, 1917, measles made its firstappearance at Camp Gordon, Ga., almost immediately assuming epidemicproportions, taxing the capacity of the hospital to its utmost. Among troopsfrom Georgia, Ala-
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bama, and Tennessee came the overwhelming preponderance ofthe measles cases, while troops transferred from Camps Upton, Dix, and Lee wererelatively free. This difference, as stated elsewhere, was apparently due to thefact that the southern troops came from rural communities and had never beenexposed to measles, whereas the northern troops were largely city dwellers.
The most serious epidemic that affected troops at CampKearny, Calif., was measles. The number of cases reached its height on January22, 1918, when 115 cases were admitted to hospital.
About the 1st of November, 1917, measles began to enter thehospital 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 aboutOctober 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 notexist 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 hospitaladmissions, or about 13 per cent.
Measles was constantly present at Camp Shelby, Miss., but atno time reached the point where it could be considered an epidemic. It increasedwith the advent of new troops, particularly those from the rural districts. Thefirst case was admitted about October 1, 1917, and, up to March, 1918, therewere 1,505 such admissions.
At Camp Sevier, S. C., measles began to appear almostimmediately upon the arrival of the first troops in the fall of 1917. It assumedepidemic proportions with some 3,500 cases. Within 10 days after the epidemicceased, measles was reintroduced into camp by the arrival of new troops.
Camp Travis, Tex., reported 4,203 cases of measles. Theheight of the epidemic occurred in the latter part of November and early inDecember, 1917. The maximum number of admissions was 175 per day. This epidemicdied 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 werecamp infections during the early months of mobilization; however, not to aserious degree. The fact that the two diseases coexisted made their handlingrather difficult as differential diagnosis was not easy. The number of cases wassmall 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. Inthe three weeks preceding the outbreak of influenza in the fall of 1918, anepidemic of measles occurred, chiefly among the soldiers from Camp Gordon.
OCCURRENCE IN THE CIVIL POPULATION
The medical profession accepts measles as a disease ofchildhood because approximately 90 per cent of the cases in civil life occurbefore the age of 10 years. The occurrence of measles in all ages, in the civilpopulation is not exactly comparable with the occurrence among the age groups asrepresented by
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soldiers, yet even with the added age groups of the civilpopulation it will be shown that measles had a greater occurrence ratio in theArmy than among the home population. Table 67 shows the reported cases ofmeasles and deaths, with ratios per thousand in the registration area of theUnited States during the period 1917-1919. The population is estimated and takenfrom public health records for the year 1918, and the total ratios for therespective years are based upon this population. This table shows that 529,498cases were reported in the registration area among a population of approximately100,000,000 persons of all ages; the annual ratio was 5.29 per 1,000 for theyear 1917. During this year 9,466 deaths were reported, giving an annual deathratio of 0.09 per thousand. During the same year the admission ratio in the Armywas 92.24 per annum and the death ratio 2.18. In other words, although all agesare included in the civilian occurrence, including the ages in which measles ismost prevalent, the disease was approximately eighteen times more common in theArmy than among the civilian population. In this connection, however, it shouldbe remembered that these figures include only reported cases in the registrationarea, and undoubtedly many cases, as well as deaths, occurred that were neverreported.
During 1918 the disease was less prevalent in the UnitedStates than it was in 1917, both among civilians and soldiers; in theregistration area 429,764 cases and 9,944 deaths were reported, with occurrenceand death ratios of 4.29 and 0.099 per thousand per annum, respectively, whilein the Army in the United States, during the same period, among enlisted menthere were, 38,447 primary admissions, with 908 deaths. The admission and deathratios were, respectively, 29.29 and 0.69 per thousand strength. During thefollowing year (1919) the number of cases and deaths was considerably less. Inthe civil population there were 178,528 cases reported with 2,316 deaths, whilein the Army 1,211 primary admissions, with 18 deaths, were recorded amongenlisted men. The occurrence ratio in the civil population was 1.78 and deathratio 0.02 per thousand, while these ratios in the Army were 3.95 and 0.06 perthousand strength. Therefore, it may be said that measles was prevalent in thecivil population in the beginning of the war and decreased in its occurrencethroughout this period. The same may be said for the occurrence in the Army.
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OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES
Among the total of the mean annual strengths for the AmericanExpeditionary Forces of 1,665,796 officers and men, there were recorded 9,168primary admissions for measles and 358 deaths. The admission and death ratiosper thousand strength, respectively, were 5.50 and 0.21. Among these cases therewas a loss of time from duty amounting to 229,745 days, giving a noneffectiveratio 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, aratio of 5.12. Colored enlisted men contributed 668 primary admissions with aratio of 5.46 per thousand strength. Of the total deaths, 318 were among whiteenlisted men and 19 among colored. There was 1 death among officers and 20 amongenlisted men, whose color was not stated. The loss of time from duty among whitetroops amounted to 189,822 days, and for colored, 16,017. The noneffectiveannual ratios were, respectively, 0.35 and 0.36. From these figures it isapparent that the occurrence of measles and the noneffectiveness were greateramong colored than among white troops. The death ratio, however, was higher forthe latter.
Occurrence by months is better shown with figures for whitethan with figures for colored enlisted men. The first cases among white troopswere reported during the month of June, 1917, when 7 primary admissions wererecorded. The number steadily increased until January, 1918, when 507 primaryadmissions were recorded. During the spring there were from 100 to 200 cases permonth; however, commencing in the late summer, the number of cases increaseduntil between 800 and 900 primary admissions were recorded per month, with thelargest number of cases during September. In 1919, the number of primaryadmissions was small, due to the withdrawal of the forces from Europe and thediscontinuance of forwarding troops from the United States. This applies to thebeginning of 1919 and not to the latter part, as recruiting was resumed andreplacements sent to the army of occupation in Germany during the latter half ofthe year, thus accounting for the increase in occurrence among those troops.
Chart L shows the trend taken by admissions and deaths forenlisted men serving in Europe. The peak was reached in July, 1917. This wasfollowed by a decrease until September, when the trend again took an upwardcourse, reaching a second but lower peak in November. Until February, 1918, theadmission ratio remained between 25 and 50 per thousand, after which time theoccurrence took a downward trend until April. From that time until the date thearmistice was signed the trend of occurrence was about horizontal. Theoccurrence diminished in December and continued through January, 1919.Commencing in the summer, the trend suddenly took an upward course, reachingapproximately 9 per thousand, followed by sudden decrease in September, reachingthe lowest admission ratio for troops in Europe during the war. During October,1919, the trend was upward, reaching approximately 35 per thousand; this was dueto replacements sent to Germany as mentioned above.
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Emerson,10 in a report oncommunicable diseases in the American Expeditionary Forces, stated that 8,207cases 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 highincidence rates in the first months, up to and including January, 1918, ascompared with the rates after that time, were probably due to the fact thatamong troops who came over before the spring of 1918 there was a very muchhigher percentage of men who had not passed through measles or been exposed toepidemics in the training camps in the United States than was the case withtroops arriving in the American Expeditionary Forces after February, 1918. Inthe first 18 months of the American Expedi-
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tionary Forces, measles was very largely confined to troopsjust arriving at base ports, or to detachments of recent arrivals at thereplacement camps or army units to which they were often hastily forwardedwithout being held over the incubation period. Between 50 and 80 per cent of allcases in the American Expeditionary Forces were reported from week to week inbase ports-that is, up to the signing of the armistice. The number variedgreatly according to the arrival of transports or convoys. After thediscontinuance of new troop arrivals and the stabilization of commands, measlesplayed but an insignificant part among diseases in the American ExpeditionaryForces. The cases that did occur after January 1, 1919, were chiefly in otherparts of the American Expeditionary Forces than the base ports, especially inthe armies and in the advance sections. Contrary to the general belief, asexpressed by medical officers in the United States, Emerson held that measles,as a precedent or contributing cause to pneumonia, played a very unimportantr?le in the American Expeditionary Forces, as it was rare.
There is no reason to believe that measles in the AmericanExpeditionary Forces was to any noticeable extent due to infections acquired bythe soldiers from association with the French civil population.10
FACTORS INFLUENCING OCCURRENCE
It is generally accepted that one attack renders theindividual lastingly immune. Recurrences in unquestionable cases are rare;therefore, with a disease so markedly contagious as measles, it is reasonable toassume that persons who have lived in close contact with others have developedmeasles in early life. This explains the larger percentage of immune personsamong city dwellers and the susceptibility among country persons. Thesecomparative facts are borne out by occurrences among recruits and drafted menobtained from urban and rural districts for the Army.
It is generally conceded that mobilization has a directbearing on the occurrence of measles. This is due to the huddling together ofsusceptibles, a condition that can not be prevented in military life. During theWorld War many of the men were not only housed in standard barracks, but theyalso had a common mess and a common amusement hall.11In all these places they came in close contact while indoors. Some camps hadcentral heating plants, while others had one or more stoves in each room.11The former camps were generally located in the northern portion of the UnitedStates; the latter were generally in camps located in the South.11Where heat was evenly distributed throughout the rooms, as in steam-heatedbarracks, men did not huddle together so much for the purpose of keeping warm orfor amusement; in camps where stoves were used, men would collect around thestoves,7and while in this close contact the virus of respiratorydiseases was spread through droplet infection. Coughing, sneezing, and spittingwere common. Outdoor exercises and duties, such as close-order drill, may havecontributed to the spread of the disease, but certainly to a far lesser degree.
The occurrence of measles in the Army shows that it is mostprevalent in the cold months. It is true it occurs during all months, butovercrowding is most common in cold weather, and as a result all acuterespiratory diseases are
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then more common. With a large number of recruits suddenlybrought into camp, collected from every environment-immunes, persons actuallysuffering from the disease, and susceptibles-often arriving in camp on thesame train, in the same cars, and placed in the same barracks, outbreaks wereinevitable.
Race as a factor is subject to question. Measles was morecommon among white than among colored troops. On the other hand, the PortoRicans suffered more than any other troops in the American Army, the occurrencebeing more than three times that among the whites. The Hawaiian troops servingin their own country suffered second. There appears to be no explanation for thegreater susceptibility of these persons over negroes. The difference in therecords may be explained by the increased difficulty in diagnosing this diseaseamong 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 ofmeasles among white and colored enlisted men from the South and from othersections of the United States is shown in Table 69. The occurrence wasapproximately four times greater among southern white enlisted men than amongwhite troops from the other sections of the country. About the same is true forsouthern colored enlisted men. Not only was this true for admission ratios, butalso for death ratios. The case fatality was slightly higher among the southernwhite enlisted men, while southern colored enlisted men had a fatality slightlybelow that of colored enlisted men from the other sections of the United States.
Race |
| 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- | 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 | --- |
| 97,251 | 2,367 | 149 | 1,865,929 | 19.2 | 24.80 | .60 | .04 | 1.30 | 2.43 | .15 |
|
| Annual ratios per 1,000 strength | Case fatality rates (per cent) | ||
| 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 |
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Officers suffered less than enlisted men. (See Table 65.) There are twopossible explanations for this: First, officers lived in individual billets orwith one or several other officers; overcrowding was the exception; theirrelationship to enlisted men did not bring them in close contact with them.Second, officers represented an older age group, and as such had greateropportunities for having contracted the disease at some prior date. Theindividual billeting of officers deserves chief attention in explaining whyofficers suffered less than enlisted men from measles.
An analysis was made of 28,837 primary admissions formeasles, white enlisted men, to determine the influence of length of service onthe occurrence of measles. Among this number, 11,528 men had less than twomonths' service when they were admitted to sick report. Including men withthree months' service, in 20,991 instances, measles occurred before these menhad been in the service 100 days. This, as will be explained below, was a matterof much importance. Continuing the analysis further, it will be seen that thenumber of cases progressively decreased with each additional month of servicefor the first year, which contributed 28,002 of the 28,837 cases analyzed.
SYMPTOMS
Repeated observations made by medical officers lead one tobelieve that measles has perhaps one of the most constant periods of incubationfor any of the eruptive diseases; that is, reckoned from the date of exposure tothe appearance of the eruption. It was 13 days, and, in fact, was so regularthat the 14-day quarantine period was considered entirely satisfactory. Reckonedfrom the date of exposure to the period of invasion, the time varied from 9 to11 days. This seemed to represent the consensus of opinion of medical officers.
The period of invasion is the most important stage from anepidemiological point of view. It is characterized by headache, chilliness,fever, mild catarrhal manifestations of the eyes, nose, throat, and bronchi, andcough. During this stage the individual does not feel sufficiently sick toreport sick or be confined to bed. It is usually impossible to diagnose thedisease during the early stages of this period, and, since the nasopharyngealsecretions have been proven to contain the virus during the stage of invasion,and since the soldier associates freely with his comrades during this time, thegreat danger of spreading the infection is obvious. Accordingly, the Office ofthe Surgeon General, the chief surgeon, A. E. F., and camp epidemiologiststhroughout the Army, repeatedly emphasized the importance of recognizing earlysymptoms of the disease. The initial symptoms, namely, coryza and catarrhalmanifestations of the eye, suggest that the infectious agent develops first inthe respiratory tract, but the primary lesion is not known.
This period merges into the period of eruption, whichmanifests 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 catarrhalinjection. On the buccal surface, Koplik spots appear. Hackett12stated 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 casesand suspects in
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the Army during the war, but their presence was onlyoccasionally reported. Generally speaking, cases in the Army were seen late inthe period of invasion and usually the diagnosis was not made until the skineruption had developed, by which time the Koplik spots are lost in the eruptionon the mucous membrane of the mouth.
The exanthem appears as red, flat, slightly elevated papulesdeveloping 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 thehair. The eruption has a dusky hue as distinguished from the bright red ofscarlatina. From these locations it spreads over the body. It was during theearly eruptive period that the vast majority of cases were admitted to ourmilitary hospitals during the World War.
The period of desquamation is characterized by a finefurfuraceous peeling of the epidermis, involving also the palms of the hands andsoles 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, itwas a practice to hold patients in quarantine in military hospitals until thisdesquamation was complete. The scales are now looked upon as harmless and,therefore, of practically no value except in diagnosis. Although measles withouteruption is recognized, there is no discoverable record of such cases in theArmy.
The urine often shows albumin, especially during the febrileperiod, and the diazo reaction is positive in about three-quarters of the cases.The latter may be of diagnostic value, especially when confusion with scarlatinaexists. This test was only sparingly used during the war.
The blood picture is not characteristic. During the period ofincubation there is a leucocytosis involving the polynuclear cells. In theperiod of invasion the number of white cells decreases; during the period oferuption there is a leucopenia; during desquamation, the number rises to normalin uncomplicated cases. This blood picture was considered of some valuein the contagious service at the base hospital, Camp Grant, Ill., during thefall of 1917 and winter of 1918, especially in distinguishing measles fromscarlet fever.13
Several types of measles are recognized, depending uponseverity such as mild, hemorrhagic, malignant, and relapsing. Generallyspeaking, the disease, as reported, was mild in the Army during the war, but notwithout exception.
Hamburger and Fox,14reportingupon two measles epidemics at Camp Taylor, Ky., said the first epidemic wasquite severe and the majority of patients were acutely ill from the start. Thesoldiers who later developed pneumonia and empyema, were particularly prostratedupon entrance to hospital, with flushed face, dusky cyanosis, full, boundingpulse, dyspnea, and labored, grunting breathing. The cyanosis was most striking,as one could almost tell from the color of the patient on admission to hospitalthat he was to develop or was already developing acute pneumonia. The type ofpneumonia varied; however, in most instances it was grouped as diffuse lobularor bronchopneumonia. This first epidemic occurred during September, October, andNovember, 1917; the second epidemic, which occurred in March, April, and May,1918, was complicated not only by measles-pneumonia but also by a
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streptococcus epidemic, and was distinctly more severe thanthe first epidemic. Patients came into the hospital more acutely ill andprostrated than during the first epidemic, and died in considerably highernumbers. They died in spite of treatment, and nothing that could be done madethe slightest impression on their condition.
COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES
In barracks where soldiers are housed, as well as in civilianinstitutions, such as asylums, schools, and other places where large numbers ofpersons live in dormitories, measles is more commonly followed by complicationsthan 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 suchorganisms as the streptococcus, which spreads principally through dropletinfection.
Among the 98,225 primary admissions to sick report during theWorld War with the diagnosis of measles, there were reported 22,809complications, sequel?, and concurrent diseases. This does not mean that 22,809cases of measles developed conditions directly attributable to it. This was thenumber of such diagnoses made after the individuals were admitted to hospital.
The more important complications and concurrent diseasesreported among the primary admissions for measles during the war are given inTable 70. As has long been known, the most important and frequent complicationsof measles are the pneumonias and otitis media. Experience during the war was noexception to this rule.
Concurrent diseases and complications |
| Deaths | Case fatality rates (per cent) | ||
| 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 |
|
| 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. Theadmission 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
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complication was otitis media. There were 3,926 cases ofmeasles reported with this complication, of which 122 resulted fatally. Theotitis media developed in 4.2 per cent of the cases. The third most commoncomplication 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 concededthat lobar pneumonia is not a common complication of measles; lobular orbronchopneumonia is the type usually seen. A review of some of the clinicalrecords indicates that not all diagnoses of lobar pneumonia following measleswere correct, and that in some instances at least the diagnosis should have beenbronchopneumonia.
Pleurisy was not an uncommon complication-there were 645cases of suppurative pleurisy and 105 of the serofibrinous variety recordedamong the primary admissions. There were 296 deaths reported among these cases.The case fatality with suppurative pleurisy was 41.55 per cent. The cases werepreceded by pneumonia. Mastoiditis was recorded in 566 cases following otitismedia. 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 acase 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 percent. Eye symptoms are common in measles, and the condition is usually one ofcatarrhal conjunctivitis, with some photophobia. Phlyctenular keratitis is notan infrequent complication or sequel of measles among children who live in poorhygienic 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 toactivate quiescent tuberculosis. Among the total primary admissions for measles,343 cases of pulmonary tuberculosis were reported, a ratio of 3.66 per 1,000measles. 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, terminatedfatally.
Francine,15atCamp Gordon, Ga., made a statistical review of pulmonary tuberculosis amongconvalescent measles cases of the 82d Division there. Orders were issueddirecting that all measles convalescents be examined for pulmonary tuberculosisone month after return to duty from the hospital. As a severe epidemic hadoccurred, it was possible for the camp tuberculosis and cardiovascular board toexamine and follow up 513 cases, which was about one-third of the total that hadbeen discharged from hospital up to that time. Among these cases the lungs werereported as normal in 461, acute bronchitis in 18, clinical evidence of chronicactive 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 ofthese cases were discharged from the service on surgeon's certificate ofdisability. Francine compared these statistical data with the results of thetuberculosis board which had examined the entire division. The tuberculosis ratefor the division was reported as 0.92 per cent, and it would appear at firstsight as if measles had been an important factor in reactivating the oldlesions. This is subject to question, as the convalescents were more thoroughlyexamined than was the division, and the diagnosis in the 16 cases mentionedabove was made after more refined and detailed examina-
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tion. He concluded that while 3.11 per cent accuratelyrepresents the number of cases of active pulmonary tuberculosis in this specialgroup, it is too high if interpreted as an index for measles as a factor in thelighting up of old tuberculous foci.
The findings by Francine are greatly in excess of thosereported by Berghoff,16at CampGrant, Ill., after having made a survey of 596 cases to determine therelationship of measles to pulmonary tuberculosis. These cases were firstexamined 14 days after admission to hospital and again at 30 days or 6 weeksafter admission. All of these patients had previously been examined fortuberculosis while in camp during the routine examination. Only three of theconvalescents showed unmistakable signs of a recent reactivation of an oldtuberculosis directly attributable to measles infection. Of these three cases,one had suspicious findings after the second examination; the second case was afrank reactivation hut, upon looking up the records, it was found that he hadbeen under observation for tuberculosis one week prior to admission to hospitalfor measles; the third case was a frank example of an active pulmonarytuberculosis resulting directly from measles infection. Berghoff concludes thatthese figures seem to show that measles is not a predisposing factor towardpulmonary tuberculosis.
Whether or not measles predisposes individuals to theoccurrence of other exanthematous diseases is not known. Among the primaryadmissions for measles, scarlet fever occurred as a concurrent disease in 344cases, diphtheria in 149, erysipelas in 108 and German measles in 38. (See Table70.) Epidemic cerebrospinal meningitis was concurrent in 93 instances and mumpsin 1,028.
Hamburger and Fox,14reportingon epidemics of pneumococcus, streptococcus, and measles infections at CampTaylor, Ky., remarked that these epidemics could be chronologically arranged infive periods. The first, covering September, October, and November, 1917, wasdesignated as the lobar pneumonia period. The second, from November, 1917, toand including January, 1918, was known as the first measles and measles-pneumonitisperiod. There were 967 cases of measles during this period, 80 of whichdeveloped pneumonia and 18 died; the case mortality was 19.4 per cent. Empyemafollowed measles-pneumonia in 18 cases, with a case fatality of 33.33. Thethird period, December, 1917, to February, 1918, was designated as thestreptococcus atpyical pneumonitis and pleuritis period. Of great interest inthis series of cases was the rapid and extensive development of empyema and thepresence of hemolytic streptococcus in the pleural exudate. The fourth periodwas known as the second measles, measles-pneumonia, and streptococcus epidemic.It covered March, April, and May, 1918. During this time there were 414 cases ofmeasles, of which 64 developed pneumonia and 17 died-a case mortality of 31per cent, as compared with 19.4 per cent in the first epidemic. Empyema followedmeasles-pneumonia in 15 instances, with a case mortality of 13 per cent. Thissecond measles, measles-pneumonia, and streptococcus epidemic was distinctlymore severe than the first epidemic. Patients came into the hospital moreacutely ill and prostrated during the latter group and
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died in considerably higher numbers. It is also noted thattwice the number developed empyema, 3.6 against 1.8 per cent, although theempyema mortality was lower. The reason given for this lower mortality wasimprovement in the methods of treating empyema. It was noted in the secondepidemic that this form of pneumonia and streptococcus sepsis occurred oftenbefore empyema had time to develop, and these cases of measles, with associatedstreptococcus sepsis and a very high mortality, were among the most severe typesof disease encountered at Camp Taylor, being comparable only with cases ofprofound general sepsis and profound toxemia. The fifth period marked thedecline of the epidemics and was for May, June, and July, 1918. During this timethere were 396 cases of measles, of which 9 developed pneumonia and died. Thecase fatality was 11.11 per cent. The total number of pneumonias of all classeswas 114, of which 8 died, giving a case fatality of 7.9 per cent. The totalnumber of empyemas was 26, with a case fatality of 15.4 per cent. This fifthperiod is interesting, as it showed marked improvement in morbidity andmortality conditions with the advent of warmer weather, although at no time wasthe 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 thediagnosis 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; epidemiccerebrospinal meningitis, 32 cases, 17 deaths; mumps, 436 cases, 1 death;pulmonary tuberculosis, 141 cases, 3 deaths; bronchopneumonia 104 cases, 15deaths; lobar pneumonia, 55 cases, with 5 deaths; influenza, 1,529 cases, with92 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. Thesestudies were conducted immediately after the subsidence of the influenzaepidemic, when the Pfeiffer bacillus may have been unduly prevalent. Of thefirst 31 cases of measles examined, the Pfeiffer bacillus was recovered in 25during the eruptive stage. Subsequent examinations showed that in three-fourthsof these patients the bacillus disappeared with the subsidence of the acutesymptoms of measles. A group of control individuals, seven in number, wereexamined, but no Pfeifferlike organisms were recovered; several reexaminationsof the control group resulted negatively. No experimental evidence was obtainedto show that these Pfeifferlike organisms have any etiologic relationship tomeasles.
Bronchopneumonia, the most important of complications,reached its apex of occurrence in January, 1918. The rate declined duringFebruary, with a slight increase in March. During 1918, 544 deaths wereattributed to this complication. Lobar pneumonia occurred most frequently as acomplication in January, following which there was a decline.
An analysis was made of 1,619 clinical records of cases ofbronchopneumonia following measles to determine the relationship of such casesto length of service. (Table 71.) Bronchopneumonia was most common among troopswith two months' service or less and decreased with each additional month upto and including one year. After that time the number of cases was too small
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on which to base any definite conclusions. These same factsapply 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 percent of the cases and 79.3 per cent of the deaths. A similar analysis (including532 cases) was made of lobar pneumonia. (See Table 72.) As withbronchopneumonia, the majority of cases were reported during the first twomonths of service, and each additional month showed a distinct diminution, notonly 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. Theseoccurrences are to be expected when it is seen that measles was most prevalentduring the first two months of service, and that it decreased progressively bymonths thereafter.
Length of service |
| Percentage rates | |||
Admissions | Deaths | Discharges for disability |
| 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 | --- | --- | --- | --- |
Length of service |
| Percentage rates | |||
Admissions | Deaths | Discharges for disability |
| 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,18discussingthe occurrence of measles in the Army camps during the winter of 1917-18,emphasized the importance of complications. At Camp Cody, N. Mex., among 235cases 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 fatalpneumonia. Among each 1,000 men with measles, 44 had pneumonia and 19 died, andof every 1,000 men without measles, 17 had pneumonia and 2 died. Vaughan furtherremarked that a person who has recently had measles is ten times more likely todie from pneumonia than a person who has not recently had measles.
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BACTERIOLOGY OF COMPLICATIONS
The most important bacteria concerned in measlescomplications during the World War were the streptococcus, pneumococcus,tubercle bacillus, and influenza bacillus. More information is necessary beforeone can state definitely the relationship that the Pfeiffer bacillus bears, notonly to measles but to influenza. The r?le played by the tubercle bacillus isone of reactivation. It is supposed that measles infection predisposes to thelighting up of old tuberculous processes, especially of the lung. Therelationship of the streptococcus and pneumococcus in measles had been underinvestigations for many years, but interest in this subject was increased by thewidespread occurrence of measles and its complications in the Army during thewar.
Inflammation of the respiratory tract during an attack ofmeasles readily permits the invasion of pathogenic bacteria. Irons and Marine,19at Camp Custer, Mich., made important observations showing that thehemolytic streptococcus had been the principal cause of bronchopneumoniaoutbreaks following measles in the military camps. Cole and MacCallum20reported, during their investigations at San Antonio, Tex., that the Streptococcushemolyticus was present in cultures of sputum coughed up from the deeperparts of the respiratory tract in 30 cases of post-measles bronchopneumonia, andmice, inoculated with sputum from 17 cases, yielded the streptococcus in 16.Blood cultures taken during life yielded the Streptococcus hemolyticus twicein 15 cases. Of the 30 cases, death occurred in at least 14, and in all the Streptococcushemolyticus was found in the lungs in practically pure cultures. Theabdominal organs were found to be free from streptococcal invasion; however,areas of interstitial bronchopneumonia were characterized by streptococcalbronchopneumonia with the streptococcus present in the pleural exudate. In thepurely lobular pneumonia areas they were present in amazingly large numbers.According to Hektoen,21 measles patients seemto become infected with hemolytic streptococci by direct droplet infection,contact, and dust infection by way of the throat; the infection also appears tospread more easily in military camps and in measles wards. Irons and Marine19found that the Streptococcus hemolyticus developed in the throat culturesof approximately 70 per cent of healthy soldiers during a period of respiratoryinfections. Cumming, Spruit, and Lynch22reported that, while 35 per cent of measles patients had streptococci in thethroat, this was the case in only 6 per cent of healthy soldiers. Cole andMacCallum20 found that 56.6 per cent of thepatients in a measles ward harbored the Streptococcus hemolyticus in thethroat, as compared with 21.4 per cent in a suspect tuberculosis ward. They alsofound the Streptococcus hemolyticus in throat cultures of 11.4 per centof measles patients on admission to hospital; after a duration of from 3 to 5days in the ward, the per cent increased to 38.6, and after 8 to 16 days to 56.8percent. These observations, according to Hektoen,21point unmistakably to the ease with which the Streptococcus hemolyticus passesfrom carrier to noncarrier and, in measles convalescence, sets up broncho-pneumonia and empyema.
Levy and Alexander,23discussing the susceptibility of measles convalescents to streptococcusinfection at Camp Taylor, Ky., showed that complications and sequel? wereresponsible for long hospitalization and high noneffective rates.
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A careful study was made of 388 cases. On admission tohospital, all cases were sent to a special ward where they remained in bed, andfrom them daily cultures were made for the streptococcus. Carriers of thisorganism were placed in "dirty wards," or wards where patients wereknown to be infected with this organism. Patients with negative throat cultureswere held for a second examination. If negative on the second examination, suchcases 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 culturesconformed to those of the throat cultures, therefore the former furnished nospecial information. Of the total cases examined, 89 or 22.9 per cent werenoncarriers and 299 or 77.1 were found to be carriers. This is in markedcontrast to the San Antonio findings, where only 11.4 per cent of measles caseswere reported as carriers of the streptococcus hemolyticus.20At Camp Taylor, Ky., the investigators found that of the noncarriers, 27became carriers while in hospital, and of the 388 cases studied, 119, or 30.6per cent, developed complications; of the latter, all except 4 were amongnoncarriers.23The complicationsthat developed in the noncarriers were acute tonsillitis, 1 case; acutebronchitis, 2 cases; cervical adenitis, 1 case. Among the carriers, 47 developedbronchopneumonia, 22 otitis media, and 15 empyema. That is, complicationsdeveloped in 36.8 percent of carriers and 6.4 per cent of clean cases; or 12.1per cent of all cases developed bronchopneumonia, of which 34 per cent developedempyema.
During the winter of 1917-18, Camp Taylor was heavilyinfected with the streptococcus hemolyticus, and almost everyorganization had representatives in hospital that showed this organism. Of the388 cases studied by Levy and Alexander23 at Camp Taylor, Ky., 346 were fromthe depot brigade, which was composed principally of troops recently arrived incamp. One company of 95 men was examined and 83.2 per cent were found to becarriers. Men composing one draft assigned to Camp Taylor were examined todemonstrate whether this high carrier rate occurred in camp or was imported. Toaccomplish this end, 489 new recruits were examined as they stepped from thetrain. The result of this examination showed that 14.8 per cent harbored the Streptococcushemolyticus; therefore, it was concluded that the men were also acquiringthe carrier state in the camp.
According to Capps,24atCamp Grant, Ill., where more than 900 cases of measles occurred during thewinter 1917-18, only 20 developed bronchopneumonia, most of which were ofstreptococcal origin. As a primary infecting organism in the causation ofrespiratory infections in our home camps, the streptococcus had a formidablerecord; but as a secondary infection, especially in pneumonia and measles, thisorganism was more dangerous than all others put together.
Clendening25studiedthe incidence of Streptococcus hemolyticus infection in lobar pneumoniafollowing measles and scarlet fever at Fort Sam Houston, Tex. To the basehospital there, from December 1, 1917, to March 1, 1918, 319 cases were admittedas primary lobar pneumonia, 44 of which became reinfected with the Streptococcushemolyticus. And among 97 cases of empyema, with 32 deaths, 18 were due tothe streptococcus. During this same period,
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there were 716 cases of measles, among which were about 150cases of otitis media, 89 cases of bronchopneumonia, 12 cases of articularrheumatism, and 2 cases of meningitis with general sepsis. All were ascribed tothe streptococcus. Knowlton,26 working at thebase hospital, Camp Jackson, S. C., reported the results of routine throatcultures from October, 1918, to May, 1919, when measles cases were examined todetermine what part the Streptococcus hemolyticus played. There were 458cases of measles in an eight weeks' period which ended December 13, 1918.Postnasal cultures were taken in these cases. The percentage of positives variedmaterially in different weeks; the lowest was 19 per cent in the fourth week andthe highest 45 per cent in the eighth week. The percentage also varied indifferent wards, the highest being in a ward where cubicles were not at firstused. A special study was then made to determine what part the streptococcusplayed in complications. Among 458 cases of measles there were 13 deaths, or 2.7per cent case fatality; 48 of the cases developed pneumonia, of which 10 showedempyema, with the Streptococcus hemolyticus as the predominatingorganism. Six deaths occurred among these empyema cases. There were 43 cases ofsuppurative oditis media, 5 of which developed mastoiditis. Knowlton found thatpneumonia and otitis media occurred in the same proportion of patients whosethroat cultures showed the streptococcus as among those whose cultures werenegative. Of 458 throat cultures, 122 were positive and 336 negative. Cases withpneumonia as a complication were positive in 10.6 per cent. The cases withotitis media as a complication were positive in 9 per cent and negative in 9.8per cent. He concluded that there was no relation between the presence of the Streptococcushemolyticus in the throat and the occurrence of complications of measles.
In an investigation of the occurrence of the streptococcus inthe 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 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 thethroats of patients admitted to hospital with measles was comparatively low.With progress of the disease, as measured by the length of stay in hospital, theproportion of patients harboring the streptococcus gradually increased.27
DIAGNOSIS
The diagnosis of measles is dependent upon clinicalmanifestations. No known serological or bacteriological findings are ofdiagnostic importance. These facts were known before the war, and experiencegained during the war furnished nothing worthy of special mention. Although acommon disease,
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and in its characteristic form readily recognized not only byphysicians, but also by the laity in the vast majority of instances, there arecases where differential diagnosis is difficult and may lead to error. Thisundoubtedly accounts for the majority, if not all, of the so-called recurrentattacks of measles. The confusion with smallpox, so often spoken of in ancientwritings, is not a matter of great concern at present, at least it did not existin the Army during the World War.
The prodromal scarlatinal type of rash may lead to thediagnosis of scarlatina, and vice versa, when patients are admitted to hospitalin this stage of measles. The diagnosis of scarlet fever may be made and laterthe typical clinical picture of measles may develop, thus leading not only toconfusion, but also to an additional diagnosis. This in all probability,accounts for some of the cases reported as a double infection of measlescomplicated by scarlatina, or vice versa.
The somewhat similar nomenclature of measles and Germanmeasles is based upon clinical manifestations and not upon the etiology. Theseconditions are recognized as distinct and separate diseases, the points ofdifferentiation being mentioned in the chapter on German measles. The necessityfor 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 inthose camps experienced some difficulty. During this period extensive epidemicsof measles prevailed in the Army camps throughout the United States. The generalhealth of Camp Lewis remained good during the latter months of 1917 except foran outbreak of German measles.28ByDecember, this disease had reached epidemic proportions and 1,000 cases werereported sick during that month. Meanwhile, there was very little plain measles;however, as the epidemic of German measles died away, true measles becamecommoner and rose to about 200 admissions per month. Indeed, for a time in thespring of 1918, Camp Lewis had more true measles than any other camp in theUnited States save Camp Cody.28Thesignificance of the apparent substitution of German measles for true measles atCamp Lewis in the early winter of 1917-18 remains unsolved. During 1917, therewere 9,244 primary admissions for German measles, Camp Lewis furnished 1,548 andCamp Cody 1,351. During this time, Camp Lewis reported 164 primary admissionsfor measles and Camp Cody 337. In view of the extensive occurrence of measles inother Army camps and the comparatively minor occurrence of German measles, itwould appear that the diagnosis of these two diseases was confused in the twocamps above mentioned.
PROGNOSIS
There appears to be no reason to believe that measles per seresulted in death or permanent disability during the war. The prognosis of thisdisease is the prognosis of its complications. Further, measles offers favorableconditions for the development of the pneumococcus and opens the doors to thestreptococcus, the organisms that were most destructive to life and left morepermanent disability in their wake among soldiers than all other known germs. Itis 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 increasedby faulty technique, faulty hospital construction for isolation, carelessattendants, poor ventilation, and overcrowding in hospitals. Conditions are mostfavorable for fatal pneumonia epidemics in military camps when the diseaseappears during cold weather and when virulent pneumococci and streptococci areprevalent. These conditions existed in the fall and winter of 1917-18.
There were 2,370 deaths recorded among the primary admissionsand 162 among cases in which measles was a concurrent disease. The case fatalitywas 2.4 per cent among the former. One hundred and forty-nine men weredischarged from the Army on account of permanent disability following admissionto hospital for measles. The majority of these cases suffered from disabilitiesdirectly attributable to pneumonia and its complications. More than 22,000complications were reported among the primary admissions for measles. Whenviewed from this standpoint, it is seen that the prognosis was not so favorablein the Army as is generally accepted among the civil population.
PREVENTIVE MEASURES
The virus of measles is contained in the nasopharyngealdischarges and in the blood at an early stage of the disease. Thuscommunicability begins, certainly, before the appearance of the exanthem and inall 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 therespiratory system led to the system of isolation, the use of sputum cups,cubicles for patients, gowns and masks for attendants, and such terminaldisinfection as was used during the World War.
Appreciating the value of immunity conferred by previousattacks for purposes of quarantine, Munson,29in 1916 caused a census to be taken at Camp Wilson, Tex., to determinefrom the statements of the soldiers whether or not they had previously hadmeasles. With this information as a basis of quarantine for contacts, along withavoidance of overcrowding in tents, the sunning of bedding and personal effects,and with proper ventilation of sleeping quarters, outbreaks of measles at CampWilson were brought under control. Munson held that measles epidemics arepreventable. He recognized that a census, based upon the soldiers' statements,is only approximately correct; however, it is sufficiently accurate forpractical purposes, and the error lies largely in the direction of the soldierreporting a previous attack of measles when he really never had it.
Sellards30 reported on acensus of susceptibility to measles and its relation to quarantine procedures atCamp Meade, Md. This census differed from that reported by Munson,29as the statement of each soldier was checked by a written report from hisparents. Discrepancies were numerous and were almost entirely in the directionof the soldier having altogether forgotten attacks of measles that occurred inearly life. To avoid prejudicing him, the soldier was given a card to complete,which showed not only measles but also scarlet fever, German measles, andmeningitis. In 144 statements of soldiers claiming measles, the parentsconfirmed them in 133. In 89 cases where soldiers reported
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no measles the parents confirmed them in 49. This shows thegreater portion, 92 per cent, of answers indicating a previous attack wasconfirmed by the parents, while, of those indicating that no previous attack ofthe disease had occurred, 55 per cent were not confirmed by statements of theparents. Sellards obtained similar results in a census at Camp Devens, Mass.31These results introduced an element of doubt into some of the conclusions drawnby 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 ofthe supposedly susceptible men, while of the 89 men at Camp Meade reportingthemselves as susceptible, more reliable information from the parents indicatedsusceptibility 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 percent 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 per1,000 strength, while approximately 19,261 nonimmunes furnished 956 cases ofmeasles, or 49.6 cases per 1,000. It was reported that the infrequency ofmeasles among the men classified as immunes had been of great assistance in theselection 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 ameasles census, this information, when it is practicable to obtain it, is ofgreat value in dealing with outbreaks of the disease.
Gittings33 reported on themilitary value of the immunity conferred by previous attacks of measles, scarletfever, and mumps at Camp Mills, Long Island. In the fall of 1917, both measlesand German measles were epidemic at that camp; and as patients were questionedon admission to the camp hospital, it was very noticeable that those sufferingfrom German measles almost invariably gave a history of having had a severeattack of true measles, while those with measles denied ever having had aprevious attack or admitted having had it only in a mild form. So noticeable wasthis that it became a factor of distinct importance in determining the diagnosisin early doubtful cases and often formed the basis for isolation into one or theother groups. Subsequent developments almost invariably substantiated thehistory. Commenting on the value of previous attacks of measles at the UnitedStates Army General Hospital No. 9, Lakewood, N. J., Gittings stated that theobservations made at Camp Mills were corroborated. These observations were basedupon an analysis of 100 Hospital Corps men transferred from Camp Greenleaf, Ga.From them it was concluded that immunity conferred by previous attacks ofmeasles, German measles, scarlet fever, and mumps should be recorded on theservice record of the soldier at his first physical examination and thatsubsequent attacks while in the service should be recorded, as this informationpossesses practically the same significant value as does the record of typhoidand smallpox prophylactic vaccinations.
Previous to the World War numerous investigators attempted toproduce active or passive immunity in measles. Various methods were employed andfavorable results reported in some instances. In so far as passive immunity is
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concerned, Sellards,31working at Camp Devens, used blood from active cases of measles on twovolunteers to test their susceptibility to measles. These men were exposed to achild in the preeruptive stage and were also thoroughly inoculated over themucous membranes of the eyes, nose, and throat with mucous secretions from thispatient. They developed no symptoms of the disease.
Attempts at the production of active immunity, not onlyagainst 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 ofmeasles among the troops quarantine methods or some form of prophylacticvaccination might be feasible. Several months prior to this, it was reportedfrom Camp Pike,35investigationswere begun on a vaccine made of the Tunnicliff coccus. The original plan was tosecure complete statistics on the vaccination of 2,000 men. Soon after this workbegan, 1,350 of the 1,500 men who had received the first inoculation weretransferred to Newport News, Va., thus making complete inoculations andobservations impossible. These were casual troops and had repeatedly beenexposed to measles. Four cases developed among the 1,350 men who had receivedthe inoculation, and 16 cases developed among 1,500 others in the same depot whohad not been vaccinated. Following the above-mentioned transfer, 500 men weregiven the first and second inoculations seven days apart. Two cases of measlesdeveloped among them between these inoculations. During the same period 15 casesdeveloped among uninoculated troops. Before a third inoculation could beaccomplished all but 146 were transferred. The 146 received a third inoculationand, in so far as was known, none developed measles. At the conclusion of theseobservations, 176 men had received the third injection. Among these there were 2cases of measles. The experiments were not considered complete or conclusive,but it was the impression that the vaccine produced some immunity, andpneumonia, 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 beadvisable, on account of the dangerous complications, to make some attempt toimmunize measles cases against streptococcus infection. A vaccine was preparedwith this in view, using various strains of streptococci obtained from thepleural cavity, heart's blood, lung, pertioneum, and cases of empyema. Aseries of 100 measles cases was used for these observations, 50 receiving thevaccine and 50 being used as a control. The vaccinated cases were given threeinjections at five-day intervals. Both test and control cases were kept underidentical conditions. Of the 50 cases so vaccinated, 2 developed streptococcusbronchopneumonia, and of the 50 control cases, 14 developed streptococcusbronchopneumonia or empyema. These results were considered sufficientlysatisfactory to warrant its continuance at Camp Gordon, and conclusions weredrawn that while there were from time to time cases of streptococcic empyema andpneumonia following measles, the condition no longer presented the menace tolife and health which it had during the winter months.
Munson,29in1916, reported the prevention of measles at San Antonio, Tex., by requiringfrequent medical examinations; the isolation of all suspects
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until a definite diagnosis could be made and of susceptiblecontacts for 14 days; the establishment of sanitary regulations to prevent thetransmission of the virus from soldier to soldier; the regulation of places ofamusement and recreation; the furling of tents to expose bedding and clothinghabitually to the sun and air for at least two hours daily; the prohibition ofthe common drinking cup and of the practice of spitting in the barracks; the useof the measles census. All of these methods were employed during the war, butwithout accomplishing the results reported by Munson.
As previously stated, during the fall of 1917 incoming troopswere assigned directly to organizations without a period of detention.7As soon as practicable incoming troops were assigned to organizations orplaced in separate detachments, quarantined with the organization but inseparate barracks for a period of 14 days. Daily examinations were made for thedetection of contagious diseases during that period. After the first 32divisions had been organized, incoming troops were assigned to a separateorganization, the depot brigade which, at times, aggregated more than 10,000 menper camp.7Segregation was attemptedin the depot brigade as far as sleeping quarters, mess, and drill wereconcerned. In some instances, troops were held in more or less effectivequarantine for the expiration of two weeks, but generally speaking theyintermingled with other members of the camp during recreation and amusement.This method was an improvement over the assignment direct of incoming troops topermanent organizations; but the depot brigade existed for the purpose ofpreliminary training for and supplying troops to the division of the camp ofwhich it was a part, and the prevention of the spread of the contagious diseaseswas not its prime function.
In the summer of 1918, detention camps were authorized forthe large cantonments.37It wascontemplated that all incoming troops would first pass through these detentioncamps where contagious diseases would be detected, patients isolated, and thecommand thus kept reasonably free. The armistice was signed before thesedetention camps were completed.
In some camps a rapid examination of incoming men was made atthe railroad station and suspicious cases were segregated.7Quarantine was operated in some, by organizations in which measlesoccurred. In some instances whole companies were quarantined for 14 days;however, in most instances only immediate contacts were quarantined. Where acommand was known to be infected, daily examinations of the entire command weremade by medical officers, throats sprayed, and precautions taken to provide goodventilation and the best feasible separation of men at night.7Cubicles were installed in some barracks, use being made of the shelterhalf as the means of separating adjacent beds; special local regulations wereissued against spitting, and soldiers were cautioned against the dangers ofcoughing and sneezing while in the vicinity of others; alternate head and footsleeping was ordered and enforced during the latter part of the war.7Dust from roads and walks was looked upon as a predisposing cause, notonly in measles, but also in other infectious diseases; hence roads were sprayedwith oil in some camps, with apparently good results in the southwestern camps.7
The proper heating and ventilating of barracks were givenserious consideration. Heating was difficult, particularly in the fall of 1917,as many of
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the heating systems were incomplete.7Many of the barrack buildings were heated with stoves and soldiershabitually congregated around them, thus increasing the dangers of dropletinfection. Orders were issued in an attempt to prevent this.7With inadequate heat it was difficult and at times impossible to enforceregulations for ventilation, so night inspections were commonly made by companyand regimental medical officers to enforce this order.7
Contact with civilians was thought by some medical officersto be a cause of introducing measles into camp. However, in the AmericanExpeditionary Forces, Emerson10 found noevidence that infection was transmitted from the civilian population to membersof the American Expeditionary Forces; no epidemics occurred after the armisticebegan, and most of the cases that did occur were reported from the armies in theadvance section. Many medical officers felt that, owing to the ease with whichthe infectious agent of measles could be transmitted from person to person andto the high susceptibility of the nonimmune, any real effort to prevent theinfection was more or less futile.10
In general, upon the detection of measles the patient wassent by ambulance to the hospital for segregation, observation, and treatment.7In the early part of the war, little or no attention was paid to thepossible spread of infection while en route to hospital, although these patientsat times were dispatched in the same ambulance with others. After the use of theface mask at Camp Grant, Ill., in the fall of 191738was reported, this means of preventing the spread of infection was applied topatients in the regimental infirmaries and in ambulances. An order was issuedthat all patients suspected of having an affection of a respiratory natureshould be masked until arrival in the proper ward at the hospital.39As the war progressed and more experience was acquired, every effort wasmade to prevent the spread of infection from the time the patient was detecteduntil arrival at his bed.
It has been the practice in military as well as in civilhospitals to segregate patients with measles from those suffering from otherdiseases. This was the aim during the war; however, the vast majority of caseswere received at the military hospitals during the second stage of the diseaseand had had ample opportunity to spread the virus to others before arriving atthe receiving ward. Once received, they were placed in specially designatedwards, where the attendants wore gowns and masks, and where sputum cups, specialdishes, and thermometers were provided for these patients.40The 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 preventdroplet infection, established the plan of masking measles patients andisolating them by means of cubicles, formed by sheets suspended on transverseand longitudinal wires stretched across the ward.41As stated above, these preventive measures were received with favor and soonadopted throughout the Army.40Thepaper sputum cup was later supplemented by the paper bag and paper napkin asreceptacles for nasal discharges. These were collected at regular intervals andburned. It was realized that separate rooms would be better than wards formeasles 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 anysuch practice in view.
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During the latter part of 1917, the problem that confrontedthe hospital was the actual care of measles in its acute stages. In December,this problem became more difficult on account of the pulmonary complications-principallypneumonia of the pneumococcus type. In the early part of 1918, the type ofpneumonia, generally speaking, became the streptococcus type, many cases ofwhich were followed by empyema. It was realized that measles infection lowersthe resistance and predisposes the individual to a great variety of otherinfections and that the mortality depends largely on the occurrence of secondaryinfections which accompany or follow the primary disease. The attention ofmedical officers in the field, therefore, was directed to the prevention ofthese secondary infections.40
Inasmuch as base hospitals could control the patients onlyfrom the time they were received in the hospital, the success of isolationdepended on the percentage of secondary infections acquired after theiradmission. Levy and Alexander23 recommendedthat all new measles patients be held in segregation until identified as cleancases or carriers and then be assigned to wards accordingly. In one ward with 15clean cases quartered with 15 contaminated cases, it was found, at the end ofone week, that only 6 noncarriers remained. In another ward of 24 patients, ofwhom 12 were carriers, only 3 remained clean at the end of a week. Thus theyshowed that clean cases became contaminated when the ward was mixed. Duringanother observation it was found that where proper segregation was maintained,strictly clean wards remained clean. They concluded that if the incidence ofcomplications in measles is to be reduced, carriers must be separated and caredfor in different wards. Lynch and Cumming42believed that the air-borne or respiratory diseases are essentiallyhand-to-mouth infections and that measures applied to prevent this willenormously reduce their occurrence. Friedman and Vaughan43remarked that in considering the prevention of measles complications, whileemphasis was rightly laid on direct transmission through droplet infection, theindirect means through attendants, utensils, etc., was being unduly neglected.They recommended cubicles of a more substantial nature than sheets: A woodenframe 8 feet long, 6? feet high, with a sheet or canvas tacked across it. Thisdevice rested on 18-inch bases and was placed between adjacent beds. Further,these authors treated cases at Camp Sevier, S. C., as bed patients untilconsidered safe as to carriers by the ward surgeon. A gown was permanently keptin each cubicle and worn by every individual who entered. Individualthermometers, wash cloths, basins, towels, and glasses were kept in eachcubicle. 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 thenplaced in large galvanized iron cans containing lye solution; medicine glasses,syringes, and ice bags were sterilized after use; the water taps and basins inthe bathrooms were washed with lye solution. The number of cases reported bythese authors is too small to base definite conclusions on; however, the abovementioned technique would be difficult to carry out in military hospitals andwould require considerable additional equipment and personnel. Nevertheless,vigilance and discipline can do much toward controlling measles.
Clendening's25 plan was tosegregate every case of pneumonia, measles, and scarlet fever for 24 hours,during which time throat cultures were made
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and examined. The disposition of the case then was determinedupon by whether or not the streptococcus was present. It was claimed that theincidence of bronchopneumonia was greatly reduced by this method.
In many, if not in all, of the camps the Streptococcushemolyticus was found associated with many cases of pneumonia thatcomplicated measles; it also occurred to a variable extent independently. Thisorganism was found in the throats of patients suffering from measles and incontacts, as well as in the throats of soldiers chosen at random. Whether it wasbrought 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 thetime of year, such as the winter season, played an important part. Otherwisethere would have been outbreaks of pneumonia due to this organism as soon asthe troops reached camp, which was not the case.44In addition, there would have been no such clear connection between themeasles curve and the pneumonia curve as was the case. Further, the principaloutbreaks of pneumonia would not have developed in winter and would not haveterminated abruptly in the spring.
The camp epidemiologist, Camp Pike, Ark., in a special reporton measles at that place, stated that owing to the crowded condition in the basehospital during the fall of 1917 measles cases were treated in barracks setaside for that purpose in each organization area.45This report was based upon the comparative results between 538 casestreated in the base hospital and 256 treated in barracks. Among the former, 51developed complications, of which 30 were pneumonia, with 11 deaths. Among thelatter, 4 developed complications, 2 of which were pneumonia; in addition, therewas 1 death following the complication of otitis media. In other words, 9.5 percent of the hospital cases and 1.6 per cent among those in barracks werecomplicated by other diseases. The death rate among the former was 2 per centand among the latter 0.4 per cent. These figures are small but significant. Theessential differences in the care of these cases were: More space afforded casestreated in barracks than in hospital; the liability to cross infection wasgreatly reduced among the barracks cases, though nursing facilities werepractically nil there, with the exception of orderlies to care for the food andexcretions 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 ofmeasles has passed. However, the danger of transfer of secondary infectingagents often is still present. The danger of spreading secondary infectionduring convalescence may be removed, to a great extent, by wearing gauze masksover the mouth and nose. This became a common practice after the dangers ofcross infection were more fully recognized.
During the major portion of the first year of ourparticipation in the war, the men were sent to duty when the temperature hadreturned to normal, desquamation was completed, and the physical condition wasapparently good. The duration of hospitalization in many instances was alsoabbreviated as far as possible on account of the urgent need for additionalbeds. This practice led observers to believe that complications occurred andthat patients were sent to duty before their physical condition justified it. Asa result, the Surgeon General issued instructions that all convalescent measlespatients would be held
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in hospital, or under observation, for at least two weeksafter the temperature had returned to normal.40Although there are no statistics available to show the value of this order, itis the consensus of opinion of medical officers that it measurably reduced thenumber of complications and deaths.
Room disinfection following measles was not a routinepractice in the Army even at the outbreak of the war. It was used in isolatedcases, but, in so far as the records show, it fell into disuse as being of novalue. The larger hospitals were provided with steam disinfectors for thesterilization 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 weremacroscopically soiled. Linen from the contagious services was run through thedisinfector before being sent to the laundry, when time and opportunity wereavailable. In isolated instances, following outbreaks of measles, regimentalsurgeons sent the blankets and mattresses of entire companies or detachments tothe hospital for disinfection.7This,too, was not a routine practice, and there is nothing in the records to indicatethat it had any influence in controlling the disease.
While the measles virus is short-lived outside of the bodyand is killed readily by exposure to sun and air, this is not true to the samedegree of organisms causing secondary infections. Bacteria causing the lattermay retain their vitality and pathogenicity for a long period after mucussecretions which contain them have dried. It was along these lines that terminaldisinfection, as applied to bedding, linen, floors, and mess equipment wasconsidered of special value.
TREATMENT
The general care of measles patients during the World Warwas that of other infectious diseases. The uncomplicated case required nospecial treatment. The treatment of measles carried out in the base hospital atCamp Jackson, which may be taken as the usual treatment used throughout theArmy, follows:47
There were no striking developments in thetreatment of measles during the war. Various methods were employed in attemptsto minimize complications, but none of them was conspicuously successful, anduntil the causative agent is identified and a potent protective serum developed,there is little hope there will be any brilliant progress in treatment. Ingeneral, treatment was directed toward keeping patients as comfortable as mightbe, supporting the strength, aiding elimination, and an effort to preventintercurrent respiratory complications. Many different methods to these endswere employed and the details varied somewhat in each hospital, and at times ineach ward. However, disturbing patients to administer some drug which,theoretically, would prevent some possible complication or be given as a placebowas not justified by the results obtained. Procedures which promised well duringthe early trials were found valueless when given the test on a larger series ofcases.
The treatment at Camp Jackson which seemed to give most comfortto the patient was briefly as follows:47
The wards were kept well ventilated but notallowed to become cold, as cold air always increased the amount of coughing. Itwas not necessary to darken the wards; however, patients were shielded fromdirect sunlight and those with marked photophobia were removed to the darkerparts of the ward. Artificial lights were carefully shaded and patients withannoying cough were grouped, as far as possible, at one end of the ward tominimize the
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disturbance that they caused to others.Laxatives were given routinely on admission and aspirin for headache ifnecessary. Patients were encouraged to drink water freely. The diet was found tobe practically self-regulating, and during the period of high temperature therewas little or no desire for food, so liquids were practically the only form ofnourishment taken. If vomiting developed, all food was withheld until it ceased,which usually occurred in 24 hours. There was much less nausea among patients sotreated than among those given food during the period of nausea, and the periodof starvation was so short that it did not impair the patient's strength. Whennausea ceased, the patient was then allowed a general diet. Mastication aided inkeeping the mouth and tongue clean and stimulated gastric digestion; liquids andsoft diets all tasted alike to the patient with a foul mouth, while solid foodswell seasoned were apt to be fairly palatable and when taken in larger amountsmaintained nutrition at a higher level. This point was important to a patientfacing the possibility of pneumonia, or some other serious disease, as a latecomplication. Not only was his resistance to infection greater, but hisrecuperative power, if infection occurs, was superior to that of anundernourished individual.
Cough was often a troublesome symptom, preventing sleep aliketo the individual and his neighbors. Cold air greatly aggravated it, as shown bythe amount of coughing at night compared with the day. It was often the customto open ward windows at night, with a distinct lowering of the room temperatureand increase in the amount of coughing. To keep the ward warm at night as wellas in the day lessened cough demonstrably. For the measles patient whose coughis due to inflammation of the upper respiratory passages, warm air is anecessity. When cough was not controlled by temperature and moisture of theroom, opium was used either in the form of codein by mouth or morphiahypodermically.
As stated above, many attempts were made to prevent thedevelopment of upper respiratory complications. Germicidal solutions were usedas a spray without success, patients washed their mouths and gargled with abland alkaline solution twice daily when they brushed their teeth, vaselinecontaining some menthol was used for local discomfort in the nose, while liquidalbolene was used if the mouth was sufficiently dry to cause discomfort. Therewas nothing to indicate that spraying was of value and the other forms oftreatment enumerated were entirely symptomatic. Special attention was paid tothe detection of complications in their early stages, and when detected thetreatment was that of the complication in question. Otitis media, especially ifdue to the Streptococcus hemolyticus, developed with surprising rapidity,and rupture of the drum membrane was observed at times in a few hours after theonset of pain. Early paracentesis was necessary for treatment and the preventionof mastoid involvement. Meningitis appeared to assume its most fulminating formwhen it developed during measles.
It was recognized early during the war that measles patientswho developed pneumonia should be isolated in wards specially designated forthat purpose, as they were a potential source of infection for others. Thereforemeasles pneumonias were cared for separately and not allowed to remain withuncomplicated measles or cared for in wards where primary lobar pneumonia orbronchopneumonia cases were. Some camps, as a routine, examined all measlesadmissions for streptococcus in throat smears, and when found the patients wereassigned to separate wards.
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Treatment of the carrier state (streptococcus) wasdisappointing. Levy and Alexander23reportedthat throat cultures made at intervals in many of the "dirty" wardsshowed that the carrier state, once acquired, persisted throughout the patient'sstay in hospital and exceptions to this rule were rare. Attempts were made atmouth disinfection without success. Neutral solutions of chlorinated soda inhalf strength, which had been in common use as a gargle and spray in many Armyhospitals, 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 thepatients discharged from the hospital at Camp Taylor, who during their stay inthe 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 SurgeonGeneral, U. S. Army for the years 1840-1920.
(2) The Medical and Surgical History of theWar of the Rebellion, Medical Volume, Part Third, 649. Government PrintingOffice, 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 sanitaryinspectors. On file, Record Room, S. G. O., 721-1.
(8) Duncan, Louis C.: An Epidemic of Measlesand Pneumonia in the 31st Division, Camp Wheeler, Ga. The Military Surgeon, Washington,1918, xlii, No. 2, 123.
(9) Histories of base hospitals in the UnitedStates. On file, Historical Division, S. G. O.
(10) Emerson, Haven: General Survey ofCommunicable Diseases in the A. E. F. The Military Surgeon, Washington,1921, xlix, No. 4, 398.
(11) Report of the Chief of the ConstructionDivision, 1919.
(12) Hackett, F. J.: Measles from theStandpoint of Military Medicine. Medical Record, New York, 1918, xciii,No. 11, 475.
(13) Personal observations.
(14) Hamburger, W. W. and Fox, H.: A Study ofthe Epidemics of Pneumococcus and Streptococcus Infections, and Measles, at CampZachary Taylor, Ky., Autumn, 1917, to Summer, 1918. On file, HistoricalDivision, S. G. O.
(15) Francine, A. P.: A Statistical Review ofthe Pulmonary and Cardiovascular Defects Found in the 82d Division, U. S.National Army, Camp Gordon, Ga., with a Report of After-Results in 500 MeaslesCases. The Military Surgeon, Washington, 1918, xliii, No. 2, 160.
(16) Berghoff, R. S.: Measles a PredisposingFactor Toward Pulmonary Tuberculosis. Illinois Medical Journal, Chicago,1919, xxxv, No. 2, 62.
(17) Sellards, A. W., and Strum, Ernest: TheOccurrence of the Pfeiffer Bacillus in Measles. Johns Hopkins HospitalBulletin, 1919, xxx, No. 345, 331.
(18) Vaughan, Victor C.: Epidemiology andPublic 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 ofthe 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 MedicalAssociation, Chicago, 1918, lxx, No. 15, 1146.
(21) Hektoen, Ludwig: The Bacteriology ofMeasles. 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 Journalof the American Medical Association, Chicago, 1918, lxx, No. 15, 1066.
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(23) Levy, R. L., and Alexander, H. L.: The Predisposition ofStreptococcus Carriers to the Complications of Measles. The Journal of theAmerican Medical Association, Chicago, 1918, lxx, No. 24, 1827.
(24) Capps, Joseph A.: The Limitation and Control ofStreptococcus and Other Respiratory Infections. War Medicine, Paris,1918, ii, No. 4, 571.
(25) Clendening, L.: Reinfection with StreptococcusHemolyticus in Lobar Pneumonia, Measles, and Scarlet Fever and Its Prevention. AmericanJournal of the MedicalSciences, Philadelphia, 1918, n. s., clvi,575.
(26) Knowlton, R. H.: Report of Throat Cultures in Measles, TheJournal of the American Medical Association, 1919, lxxii, No. 21, 1524.
(27) Letter from Lieut.-Col. Eugene L. Opie, M. C., to theSurgeon General, October 31, 1918. Subject: Investigation of pneumonia andmeasles 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 anOutbreak 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 Measlesand its Relation to Quarantine Procedures. The Military Surgeon, Washington,1919, xlv, No. 5, 562.
(31) Sellards, A. W.: Insusceptibility of Man to Inoculationwith 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 ofthe Immunity Conferred by Previous Attacks of Measles, Scarlet Fever and Mumps. TheMilitary 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 ofmeasles. 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. Onfile, 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 ofOperations, to the Assistant Secretary of War, August 20, 1918. Subject:Additional construction in National Army and National Guards camps. (Approval ofSecretary 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 inControl of Contagious Disease. The Journal of the American MedicalAssociation, Chicago, 1918, lxx, No. 13, 910.
(39) Circular Letter No. 1, Surgeon General's Office, March25, 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 R?le of the Handin the Distribution of the Influenza Virus and the Secondary Invaders. TheMilitary Surgeon, Washington, 1918, xlii, 597.
(43) Friedman, J. C., and Vaughan, W. T.: Comments on theMethods Employed in Preventing Measles Complications. The Medical Clinics ofNorth 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, HistoricalDivision, S. G. O.
(45) Letter from the camp epidemiologist to the camp surgeon,Camp Pike, Ark., January 3, 1919. Subject: Special report on measles duringSeptember, October, and November, 1918. On file, Historical Division, S. G. O.
(46) Based on plans for base hospitals. On file, HistoricalDivision, S. G. O.
(47) Memorandum on measles by Maj. Charles H. Lawrence, M. C.,U. S. Army. On file, Historical Division, S. G. O.
