Communicable Diseases, Table of Contents

CHAPTER XIV

GERMAN MEASLES

STATISTICAL CONSIDERATIONS

German measles was not of particularimportance to the Army during the World War and did not rank among the 30 mostcommon diseases. There were 17,378 primary admissions for the total Army of morethan four million officers and men, giving a ratio of 4.21 per 1,000 strength.(Table 76.) There were 524 primary admissions for officers and 17,039 forAmerican officers and enlisted men. The admission ratios were, respectively,2.54 and 4.16 per 1,000 per annum. There were 16,192 primary admissions forwhite American troops and 259 for colored American troops, giving admissionratios of 4.50 and 0.90 per 1,000 strength, respectively. There were 64 primaryadmissions where the clinical records did not specify color.

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

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TABLE 76.-German 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 ratios per 1,000

	Total mean annual strengths	Admissions		Deaths		Discharges for disability		Days lost (absolute numbers)	Non- effective (ratio per 1,000 strength)
		Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per  1,000 strength	Absolute numbers	Ratios per 1,000 strength
Total officers and enlisted men, including native troops	4,128,479	17,378	4.21	82	0.02	1	0	211,645	0.14
Total officers and enlisted American troops	4,092,457	17,039	4.16	82	.02	1	0	209,413	.14
Total officers	206,382	524	2.54	---	---	---	---	4,842	.06
Total American troops:
White	3,599,527	16,192	4.50	77	.02	---	---	198,684	.15
Colored	286,548	259	.90	4	.01	1	0	4,930	.05
Color not stated	---	64	---	1	---	---	---	957	---
Total	3,886,075	16,515	4.25	82	.02	1	0	204,571	.14
Total native troops (enlisted)	36,022	339	9.41	---	---	---	---	2,232	.17
Total Army in United States, including Alaska:
Officers	124,266	475	3.82	---	---	---	---	4,336	.10
White enlisted	1,965,297	15,449	7.86	74	.04	---	---	188,378	.26
Colored enlisted	145,826	243	1.67	4	.03	1	.01	4,616	.09
Total enlisted	2,111,123	15,692	7.43	78	.04	1	0	192,994	.25
Total officers and men	2,235,389	16,167	7.23	78	.03	1	0	197,330	.24
U.S. Army in Europe, excluding Russia:
Officers	73,728	31	.42	---	---	---	---	380	.01
White enlisted	1,469,656	473	.32	3	.00	---	---	6,998	.01
Colored enlisted	122,412	12	.10	---	---	---	---	197	0
Color not stated	---	63	---	1	---	---	---	930	---
Total enlisted	1,592,068	548	.34	4	.00	---	---	8,125	.01
Total officers and men	1,665,796	579	.35	4	.00	---	---	8,505	.01
Officers other countries	8,388	18	2.15	---	---	---	---	126	.04
U.S. Army in Philippine Islands:
White enlisted	16,995	16	.94	---	---	---	---	125	.02
Colored enlisted	4,456	---	---	---	---	---	---	---	---
Total enlisted	21,451	16	.75	---	---	---	---	125	.02
U.S. Army in Hawaii:
White enlisted	16,161	46	2.85	---	---	---	---	1,119	.19
Colored enlisted	3,319	1	.30	---	---	---	---	71	.06
Total enlisted	19,480	47	2.41	---	---	---	---	1,190	.17
U.S. Army in Panama: (White enlisted)	19,688	9	.46	---	---	---	---	82	.01
U.S. Army in other countries not stated:
White enlisted	(a)	63	---	---	---	---	---	823	---
Colored enlisted	(a)	1	---	---	---	---	---	31	---
Color not stated	---	1	---	---	---	---	---	27	---
Total	14,232	65	4.57	---	---	---	---	881	.17
Transports:
White enlisted	97,498	136	1.40	---	---	---	---	1,159	.03
Colored enlisted	10,535	2	.19	---	---	---	---	15	0
Total	108,033	138	1.28	---	---	---	---	1,174	.03
Native troops enlisted:
Philippine Scouts	18,576	58	3.12	---	---	---	---	700	.10
Hawaiians	5,615	24	4.27	---	---	---	---	184	.09
Porto Ricans	11,831	257	21.72	---	---	---	---	1,348	.31

^aSeparate strength of white andcolored not available.

It has long been known that German measles is not a fatal disease; thereforeall deaths reported for the Army during the World War were, in all probability,due to some concurrent disease. Table 76 shows a total of 82 deaths charged toGerman measles, 77 of which were among white American troops, 4 among coloredAmerican troops, and 1 color not stated. The death ratio was 0.02 per 1,000strength. One case was discharged from the service on account of disabilityfollowing this disease. This was a colored American soldier. The permanentdisability was due to some other cause.

From the standpoint of noneffectiveness, German measles was a disease of someimportance to the Army during the World War. Based on the comparative number ofdays lost, it stood forty-ninth on the list of common diseases. For the totalArmy, there were 211,645 days lost from duty, giving a noneffective ratio of0.14 per 1,000 strength. By far the greater proportion of the time lost wasamong the white enlisted men. They lost 198,684 days, as compared with 4,930days lost by colored enlisted men. The noneffective ratios were, respectively,0.15 and 0.05 per 1,000 per annum. Table 76 shows 4,842 days lost by officers,giving a noneffective ratio slightly higher than that for colored enlisted men.This ratio was 0.06 per 1,000 strength.

The highest admission and noneffective ratios for the total Army were fornative enlisted troops. Among a mean strength of 36,022 native troops

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(Table 76) there were 339 primary admissions, with a loss of2,232 days from duty. The admission and noneffective ratios per 1,000 strengthwere 9.41 and 0.17, respectively. The native troops served in their nativecountries.

CHART LI

OCCURRENCE IN THE ARMY IN THE UNITED STATES

Table 76 shows 16,167 primary admissions for the Armystationed in the continental United States. This number represents the vastmajority of the cases reported during the war, most of which were among whiteenlisted men. The admission ratio was 7.23 per 1,000 strength. An analysis ofthese cases shows 15,449 among white and only 243 among colored enlisted men.The

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ratios per 1,000 strength were 7.86 and 1.67, respectively.This disease was more common among officers than among the colored troops; therewere 475 primary admissions for the former, a ratio of 3.8 per 1,000 per annum.

According to the system of recording deaths, 74 deaths amongwhite and 4 among colored enlisted men in the United States were charged toGerman measles. The death ratios were 0.04 and 0.03, respectively. The numberreported was so small that, even if they could correctly be attributed to Germanmeasles, they would make this a disease of minor importance to the Army duringthe war.

The importance of this disease to the Army was principally inthe number of days lost from duty. Table 76 shows that the officers and menstationed in the United States lost 197,330 days from duty on account of Germanmeasles. As would be expected, this was principally among the white enlistedmen, since the disease was much more common among them. The noneffective ratiofor the total Army in the United States was 0.24 per 1,000 per annum.

The occurrence of German measles by camps in the UnitedStates showed wide divergence. (Table 77.) The largest number of primaryadmissions was reported from Camp Lewis, Wash., where 1,555 cases were reportedduring the war, the admission ratio per 1,000 strength being 32.54. Camp Cody,N. Mex., was second, with 1,351 primary admissions, the admission ratio, 59.68per 1,000 strength, being the highest for any camp in the United States. Theaverage admission ratio for all camps in the United States was 7.81.

Though German measles was reported from practically allcamps, there were no areas where it could properly be called endemic. Camp Pike,Ark., reported but 11 primary admissions. This is of special interest, since theendemic diseases at Camp Pike, in many instances, were above the average.

Colored troops contributed less than one-fiftieth of thetotal admissions of 9,915 from the larger camps, there being only 210 primaryadmissions among them.

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TABLE 77.-German measles. Admissions anddeaths, by camps of occurrence, white and colored enlisted men, United StatesArmy, with ratios per 1,000 strength, and case fatality rates, April, 1917, toDecember, 1919

Camps	Average strength for period	White enlisted men				Colored enlisted men				White and colored enlisted men
		Admissions		Deaths		Admissions		Deaths		Admissions		Deaths		Case fatality rates (per cent)
		Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per  1,000 strength	Absolute numbers	Ratios per  1,000 strength	Absolute numbers	Ratios per  1,000 strength	Absolute numbers	Ratios per  1,000 strength	Absolute numbers	Ratios per  1,000 strength
Camp Beauregard, La.	20,625	18	0.89	0	0	1	2.37	0	0	19	0.92	0	---	---
Camp Bowie, Tex.	26,193	31	1.23	1	.04	0	0	0	0	31	1.18	1	0.03	3.23
Camp Cody, N. Mex.	22,636	1,351	59.68	6	.27	---	---	---	---	1,351	59.68	6	.27	.44
Camp Custer, Mich.	37,631	180	4.96	1	.03	1	.74	0	0	181	4.81	1	.03	.55
Camp Devens, Mass.	47,921	363	7.94	1	.02	12	5.41	0	0	375	7.83	1	.02	.27
Camp Dix, N. J.	49,786	322	7.16	0	0	7	1.45	0	0	329	6.61	0	0	---
Camp Dodge, Iowa	39,032	100	3.01	1	.03	54	9.30	3	.52	154	3.95	4	.10	2.60
Camp Doniphan, Okla.	26,747	208	7.78	4	.15	---	---	---	---	208	7.78	4	.15	1.92
Camp Eustis, Va.	6,780	7	1.11	0	0	0	0	0	0	7	1.03	0	0	---
Camp Forrest, Ga.	8,980	1	.11	0	0	---	---	---	---	1	.11	0	0	---
Camp Fremont, Calif.	15,414	72	4.67	1	.06	---	---	---	---	72	4.67	1	.06	1.39
Camp Funston, Kans.	56,222	515	10.29	0	0	5	.81	0	0	520	9.25	0	0	---
Camp Gordon, Ga.	44,871	283	7.44	5	.13	31	4.54	0	0	314	7.00	5	.11	1.59
Camp Grant, Ill.	49,256	36	.85	0	0	0	0	0	0	36	.73	0	0	---
Camp Greene, N.C.	29,710	23	.88	0	0	0	0	0	0	23	.77	0	0	---
Camp Greenleaf, Ga.	11,959	33	2.76	0	0	---	---	---	---	33	2.76	0	0	---
Camp Hancock, Ga.	37,994	681	18.71	1	.03	1	.63	0	0	682	17.95	1	.03	.15
Camp Humphreys, Va.	12,836	26	2.67	0	0	3	.97	0	0	29	2.26	0	0	---
Camp Jackson, S.C.	42,011	454	12.31	3	.08	30	5.85	0	0	484	11.52	3	.07	.62
Camp Johnston, Fla.	22,267	48	2.42	0	0	1	.41	0	0	49	2.20	0	0	---
Camp Kearny, Calif.	25,472	456	17.90	0	0	---	---	---	---	456	17.90	0	0	---
Camp Lee, Va.	57,635	549	10.76	9	.18	15	2.26	0	0	564	9.79	9	.16	1.60
Camp Lewis, Wash.	47,792	1,548	32.75	4	.08	7	13.34	0	0	1,555	32.54	4	.08	.26
Camp Logan, Tex.	27,734	217	8.14	2	.08	4	3.74	0	0	221	7.97	2	.07	.90
Camp MacArthur, Tex.	25,271	48	1.97	0	0	0	0	0	0	48	1.90	0	0	---
Camp McClellan, Ala.	28,664	30	1.13	0	0	1	.47	0	0	31	1.08	0	0	---
Camp Meade, Md.	50,033	447	10.65	0	0	29	3.60	0	0	476	9.51	0	0	---
Camp Mills, N.Y.	24,197	313	13.64	0	0	2	1.59	0	0	315	13.02	0	0	---
Camp Pike, Ark.	49,587	11	.27	0	0	0	0	0	0	11	.22	0	0	---
Camp Sevier, S.C.	27,786	61	2.33	1	.04	0	0	0	0	61	2.20	1	.04	1.64
Camp Shelby, Miss.	30,432	36	1.25	0	0	0	0	0	0	36	1.18	0	0	---
Camp Sheridan, Ala.	26,507	367	14.32	0	0	1	1.13	0	0	368	13.88	0	0	---
Camp Sherman, Ohio	42,750	29	.78	0	0	0	0	0	0	29	.68	0	0	---
Camp Syracuse, N.Y.	3,367	1	.30	0	0	---	---	---	---	1	.30	0	0	---
Camp Taylor, Ky.	46,962	307	7.21	5	.12	2	.46	0	0	309	6.58	5	.11	1.62
Camp Travis, Tex.	44,264	26	.69	0	0	1	.15	0	0	27	.61	0	0	---
Camp Upton, Long Island, N.Y.	44,871	174	4.33	1	.02	0	0	0	0	174	3.88	1	.02	.57
Camp Wadsworth, S.C.	31,809	309	10.25	1	.03	0	0	0	0	309	9.71	1	.03	.32
Camp Wheeler, Ga.	25,726	24	1.00	0	0	0	0	0	0	24	.93	0	0	---
Others	339	---	---	---	---	2	5.90	0	0	2	5.90	0	0	---
Total	1,270,069	9,705	8.37	47	.04	210	1.90	3	.03	9,915	7.81	50	.04	.50

 

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When viewed by months and seasons of occurrence, the majorityof primary admissions were reported in the United States for November-December,1917, and January-February, 1918, and among white troops. During these months,there were 2,133, 4,313, 2,980, and 1,139 primary admissions, respectively.During the fall of 1918 and the winter and spring of 1919, German measles was ofbut little importance to the Army.¹ It is probable that the occurrence duringthe winter of 1917-18² was due tothe comparatively large amount of nonimmune material in the Army and toconfusion in diagnosis.

TABLE 78.-German measles.Admissions, by months, white and colored enlisted men, United States Army,United States and Europe. Absolute numbers and ratios per 1,000, April, 1917, toDecember, 1919

Month  and year	White troops
	United States					Europe
	Mean strengths	Admissions		Deaths		Mean strengths	Admissions		Deaths
		Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength		Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength
1917
April	183,758	164	10.71	1	0.07	---	---	---	---	---
May	245,454	359	17.55	---	---	626	---	---	---	---
June	309,205	425	16.49	---	---	12,794	1	0.89	---	---
July	458,817	289	7.56	---	---	28,821	11	4.58	---	---
August	562,714	190	4.05	---	---	50,882	9	2.12	---	---
September	776,466	331	5.12	---	---	70,266	52	8.88	---	---
October	1,032,244	367	4.27	1	.01	92,139	8	1.04	---	---
November	1,061,422	2,133	24.11	8	.09	123,429	49	4.76	---	---
December	1,129,065	4,313	45.84	24	.26	160,178	29	2.17	---	---
Total 1917	479,929	8,571	17.86	34	.07	44,928	159	3.54	---	---
1918
January	1,096,434	2,980	32.62	16	.18	193,264	65	4.04	---	---
February	1,095,039	1,139	12.48	6	.07	223,130	11	.59	---	---
March	1,129,223	788	8.37	10	.11	283,268	16	.68	---	---
April	1,168,558	608	6.24	2	.02	388,048	19	.59	---	---
May	1,197,757	500	5.01	2	.02	587,240	24	.49	---	---
June	1,303,746	268	2.47	1	.01	796,427	8	.12	---	---
July	1,328,513	126	1.14	1	.01	1,063,192	4	.05	---	---
August	1,284,247	75	.70	1	.01	1,266,592	13	.12	---	---
September	1,321,440	52	.47	---	---	1,527,793	23	.18	2	.02
October	1,343,933	20	.18	1	.01	1,635,321	7	.05	---	---
November	1,255,195	9	.09	---	---	1,682,836	6	.04	---	---
December	941,219	65	.83	---	---	1,591,692	14	.11	---	---
Total 1918	1,205,442	6,630	5.50	40	.03	936,589	210	.22	2	.002
1919
January	672,937	67	1.19	---	---	1,488,683	22	.18	---	---
February	471,815	62	1.58	---	---	1,310,083	16	.15	---	---
March	406,839	66	1.95	---	---	1,115,693	23	.25	---	---
April	339,836	36	1.27	---	---	853,425	18	.25	---	---
May	291,810	11	.45	---	---	569,842	10	.21	---	---
June	246,903	2	.10	---	---	271,633	9	.40	---	---
July	215,104	1	.06	---	---	111,634	1	.11	---	---
August	156,791	1	.08	---	---	48,006	1	.25	---	---
September	149,360	1	.08	---	---	30,315	---	---	---	---
October	139,877	---	---	---	---	21,055	3	1.71	---	---
November	132,403	---	---	---	---	18,920	---	---	---	---
December	135,441	1	.09	---	---	18,379	1	.65	1	.65
Total 1919	279,926	248	.88	---	---	488,139	104	.21	1	.002
Total for period	1,965,297	15,449	7.86	74	.04	1,469,656	473	.32	3	.00

 

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TABLE 78.-German measles. Admissions, by months,white and colored enlisted men, United States Army, United States and Europe.Absolute numbers and ratios per 1,000, April, 1917, to December, 1919-Continued

Month and year	Colored troops
	United States					Europea
	Mean strengths	Admissions		Deaths		Mean strengths	Admissions
		Absolute numbers	Ratios per 1,000 strength	Absolute numbers	Ratios per 1,000 strength		Absolute  numbers	Ratios  per 1,000  strength
1917
April	4,870	2	4.93	---	---	---	---	---
May	5,826	3	6.17	---	---	---	---	---
June	5,171	1	2.32	---	---	---	---	---
July	6,675	---	---	---	---	---	---	---
August	8,519	1	1.41	---	---	---	---	---
September	9,409	1	1.28	---	---	---	---	---
October	21,795	---	---	---	---	935	---	---
November	39,225	30	9.18	---	---	2,392	4	20.10
December	36,851	20	6.51	---	---	5,346	---	---
Total 1917	11,529	58	5.03	---	---	723	4	5.50
1918
January	50,705	37	8.76	---	---	8,673	2	2.77
February	49,955	13	3.12	1	.24	9,664	1	1.24
March	54,814	4	.88	---	---	11,541	---	---
April	59,015	22	4.47	2	.41	12,667	2	1.89
May	87,650	75	10.27	1	.14	28,279	---	---
June	89,305	12	1.61	---	---	33,208	1	.36
July	124,976	2	.19	---	---	47,171	1	.25
August	168,422	2	.14	---	---	78,734	---	---
September	164,846	3	.22	---	---	91,270	---	---
October	182,705	---	---	---	---	138,827	---	---
November	150,587	---	---	---	---	148,679	---	---
December	104,140	1	.12	---	---	148,372	---	---
Total 1918	107,260	171	1.59	4	.04	63,090	7	.11
1919
January	68,337	6	1.05	---	---	140,396	---	---
February	66,104	1	.18	---	---	131,219	---	---
March	44,634	5	1.34	---	---	123,152	1	.10
April	29,824	2	.81	---	---	119,801	---	---
May	20,780	---	---	---	---	108,650	---	---
June	18,562	---	---	---	---	64,166	---	---
July	20,058	---	---	---	---	12,508	---	---
August	18,013	---	---	---	---	1,741	---	---
September	11,322	---	---	---	---	1,287	---	---
October	9,084	---	---	---	---	185	---	---
November	8,792	---	---	---	---	83	---	---
December	8,935	---	---	---	---	---	---	---
Total 1919	27,037	14	52	---	---	58,599	1	.02
Total for period	145,826	243	1.67	4	.03	122,412	12	.10

^aNo deaths reported for colored enlisted men in Europe.

The difference between the primary admissions reported from camps, as shownin Table 77, and the total number of primary admissions reported for the UnitedStates as a whole is accounted for by troops who had stations other than in thelarger camps. Among these were 6,252 primary admissions.

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OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES

The distribution of German measles among the AmericanExpeditionary Forces was of far less importance, from every point of view, thanin the United States. There were 579 primary admissions in the AmericanExpeditionary Forces, with a total mean annual strength of one and a halfmillion men; the admission ratio was 0.35per 1,000 per annum. White enlisted men contributed most of the cases. Therewere 473 primary admissions among the white enlisted men, 12 among coloredenlisted men, and 63 where color was not stated. Officers contributed 31 primaryadmissions and had the highest admission ratio for any American troops inEurope. This ratio was 0.42 per 1,000 per annum. The admission ratios for whiteand colored enlisted men in Europe, respectively, were 0.32 and 0.10 per 1,000per annum.

From the standpoint of time lost, this disease was ofcomparatively little importance to the American Expeditionary Forces-there wasa total of 8,505 days lost, 6,998 of which were for white enlisted men, 197 daysfor colored enlisted men.

EPIDEMIOLOGY

Though the exciting cause of German measles is unknown, thereis no question as to the identity ofthis disease or as to its contagious nature. Its infectiousness seems less thanthat of measles and scarlet fever and to be of but short duration. Table 76indicates that the negro possesses a relatively high degree of immunity toGerman measles or that the disease was frequently not accurately diagnosed,since the number of admissions was much greater among white than among coloredtroops. According to experiences in the United States Army during the World War,the seasonal occurrence of this disease was that of the other exanthematousdiseases; in other words, it was most common during the fall, winter, and earlyspring months. The highest admission ratio, 9.41, was for native enlistedtroops. If this is to be taken as an index of immunity, the native troops,particularly the Porto Ricans, are more susceptible to German measles than are even the whiteAmerican troops.

It is very probable that the infectious agent is contained inthe nasopharyngeal discharges of the patient-at least during the catarrhalstage of the disease.

PROGNOSIS

The available records contain no case where death whichoccurred during the course of an attack of German measles could not beattributed to some other cause.

SYMPTOMS

Patients afflicted with German measles neither appear norfeel very ill. There is a great diversity of opinion as to the duration of theincubation period. Geiger reported the average incubation period among 173 casesstudied as 17 days, the shortest being 11, and the longest 21 days.³ Vaughangave the wide range of from 5 to 21 days.⁴

Premonitory symptoms are usually present and consist ofmalaise and mild headache, slight sore throat and, exceptionally, toxicsymptoms, such as pain in the joints. Gastrointestinal symptoms are exceptional.There may be elevated temperature with a chilly sensation during this stage, orboth may

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be absent. The duration of this stage is characteristicallyshort, and the skin rash usually makes its appearance within 24 hours. Someauthors state that an enanthem is constantly present and consists of a macularrose-red eruption in the throat. It was on this account that German measles wasoriginally regarded as a hybrid, having the sore throat of scarlet fever and therash of measles. The mastoid and occipital lymph glands are usually enlarged andpainful. Although this adenitis usually occurs late in the disease, it issometimes one of the earliest symptoms and the physician's attention may beattracted to it by the complaint of tenderness and stiffnessof the neck.

The eruption may be the first sign of the disease to attractattention. It appears on the face and, unlike scarlet fever, involves theperioral region. In the beginning it is usually discrete, macular, somewhatpunctate, slightly elevated, and disappears easily on pressure. Itching isusually not present.

Geiger reported 15 recurrences in a study of 173 cases.³In 5 cases there were three separate attacks. In 2 cases, the secondattack occurred three weeks after the first and was followed by a third attackfive weeks later.

COMPLICATIONS AND SEQUEL?

Geiger reported that complications were not infrequent in hiscases, nor were they of a mild type.³ Acute arthritis was noted in 36of his cases. Recovery was slow. In 4 cases hemolytic streptococcus was obtainedin pure culture from the knee joint. In two cases acute nephritis was noted.Endocarditis was a complication in 1case and otitis media in 8. Neither pneumonia nor jaundice was reported byGeiger.

The statistical records of the Surgeon General's Office forthe World War period show 38 cases of German measles reported as concurrent withmeasles and 32 cases as concurrent with scarlet fever. Conversely, there were 21cases of measles and 54 cases of scarlet fever recorded as concurrent withGerman measles, the only difference between these two classes being a questionof which disease was reported as the primary cause of admission. There were nodeaths among these cases.

DIAGNOSIS

The diagnosis of German measles is based upon the mildness ofonset, the mildness of symptoms and signs, the incubation period, specialadenopathy, and characteristics of the skin eruption. The differential diagnosisbetween German measles, measles, and scarlet fever is mostimportant. Measles is differentiated by the following diagnostic points: Theincubation period is shorter, and catarrhal symptoms of the respiratory tractare more pronounced. The differential diagnosis between German measles of thescarlatiniform type of rash and scarlet fever is more difficult. The distinctivepoints in favor of the latter are the shorter incubation period; more severeinitial symptoms, as vomiting, sore throat, fever, headache, rapid pulse,"strawberry tongue," greater tendency to complications, andcharacteristics of the skin eruption.

Toxic and drug rashes at times must be differentiated fromthe rash of German measles. The former skin rashes are irregularlydistributed and they are polymorphous in character. Glandular involvement andcatarrhal affections of the respiratory tract are absent in the toxic and drugrashes.

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Confusion in diagnosis undoubtedly existed in the early partof the war period, more especially in the fall of 1917. This is believed toaccount for the occurrence of German measles in epidemic proportions in somecamps and its practical absence in others. No other explanation can be offeredto account for these differences, since the military conditions were the same.The camp surgeon at Camp Lewis reported that German measles was epidemic inNovember and December, 1917, with a total of 1,203 cases; however, that figureshould be considered advisedly, as there was at that time still some confusionas to the diagnosis. This was the camp that reported the largest number ofcases. The difficulty seems to have been principally in differentiating measles,which was epidemic in the camps at that time. Table 79, prepared from a selectedgroup of camps, shows that, generally speaking, where the admission rate formeasles was above the average forcamps in the United States the rate for German measles was lower than theaverage; and, vice versa, where the rate for German measles was high the ratefor measles was below the average. This table shows a close similarity in thetrend of scarlet fever with that of German measles when compared as aboveoutlined and would indicate confusion in the diagnosis of these three diseases.

TABLE 79.-Comparative occurrence, measles, German measles, and scarlet fever, in a selected group of camps in the United States, 1917 and 1918. Ratios per 1,000

Camp	1917			1918
	Measles	German measles	Scarlet  fever	Measles	German  measles	Scarlet  fever
Beauregard, La.	461.69	1.26	0	26.74	0.33	0.19
Bowie, Tex.	444.72	3.97	.27	2.93	.06	.42
Cody, N. Mex.	41.86	176.18	2.56	12.52	2.67	2.36
Lewis, Wash.	12.67	114.82	8.67	23.67	10.67	12.69
Pike, Ark.	477.47	.12	34.26	74.11	.25	5.71
Sevier, S.C.	371.40	2.94	0	33.66	1.89	2.03
Travis, Tex.	452.65	2.23	.82	19.77	.37	.53
Wheeler, Ga.	508.86	3.30	.35	4.27	.26	.16
Wadsworth, S.C.	.87	9.58	.11	16.63	10.38	1.22
Total for camps	120.92	21.20	2.69	22.58	3.44	2.48

PROPHYLACTIC MEASURES

There are no known specific prophylactic measures for Germanmeasles. Separation of soldiers from their commands and isolation until allevidences of the disease had ceased were the bases of prevention used during thewar. The incubation period is the best index for handling contacts.

TREATMENT

There is no known specific treatment for German measles.There is no record of any special work along these lines during the World War.The disease is mild, as a rule, and symptomatic treatment, in general, usuallysuffices. The treatment of complications is entirely symptomatic.

REFERENCES

(1) Annual Report of the Surgeon General, U. S. Army, 1920, 167.

(2) Ibid., 1919, Vol. I, 877.

(3) Geiger, J. C.: Epidemic of German Measles in a City Adjacent to an Army Cantonment. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 24, 1918.

(4) Vaughan, Victor C.: Epidemiology and Pub]ic Health. C. V. Mosby Co., St. Louis, 1922, 179.

(5) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. I, 878.