The foregoing statements are based on results obtained in an attempt to separate streptococcus carriers from noncarriers in a limited group of cases of influenza at Camp Pike, the investigation being conducted during a secondary wave of influenza between November 27 and December 5. A special group of five wards consisting of one receiving ward and four distributing wards were set aside for the study. Cubicles, masks and gowns were in use and the wards were not crowded. The personnel on these wards did not carry S. hemolyticus in their throats. Patients entering the receiving ward were assigned to beds in rotation. Throat cultures were made on blood agar plates at time of admission. The plates were examined promptly the next morning, the diagnosis of S. hemolyticus being made by the characteristic hemolytic colonies and microscopic examination of stained smears. By this method a report reached the receiving ward at 9:30 a.m. and patients were promptly evacuated to the streptococcus and nonstreptococcus wards, where they were again assigned to beds in rotation, remaining confined in bed until convalescent. Confirmation of all strains of hemolytic streptococcus was subsequently carried out by isolation in pure culture, bile solubility test, and hemolytic test with washed sheep corpuscles. All cases free from hemolytic streptococci at time of admission who were sent to the “clean” wards were recultured daily throughout the period of study, those acquiring a hemolytic streptococcus being transferred to a streptococcus ward as soon as the bacteriologic diagnosis was made. The results are shown in Table XXVI.
| Table XXVI | ||||||
|---|---|---|---|---|---|---|
| S. Hemolyticus in Cases of Influenza | ||||||
| DATE | PATIENTS ADMITTED TO RECEIVING WARD | THROAT CULTURES ON ADMISSION. S. HEMOLYTICUS: | “CLEAN” CASES ACQUIRING S. HEMOLYTICUS IN THE HOSPITAL | |||
| + | − | WHILE IN REC. WARD | WHILE IN “CLEAN” WARD | TOTAL | ||
| Nov. 27 | 12 | 4 | 8 | 0 | 2 | 2 |
| Nov. 28 | 8 | 2 | 6 | 0 | 1 | 1 |
| Nov. 29 | 17[[56]] | 8 | 9 | 1 | 2 | 3 |
| Nov. 30 | 11 | 2 | 9 | 3 | 0 | 3 |
| Dec. 1 | 10 | 5 | 5 | 0 | 0 | 0 |
| Dec. 2 | 37 | 16 | 21 | 1 | 1 | 2 |
| Dec. 3 | 21 | 8 | 13 | 0 | 2 | 2 |
| Dec. 4 | 32[[56]] | 11 | 21 | 4 | 2 | 6 |
| Dec. 5 | 17 | 10 | 7 | 5 | 0 | 5 |
| Totals | 165 | 66 | 99 | 14 | 10 | 24 |
One hundred and sixty-five cases were admitted to the receiving ward during the period of study as cases of influenza. Of these, 137 had influenza; 4 of those with influenza had pneumonia at time of admission, 23 had acute follicular tonsillitis, 3 epidemic cerebrospinal meningitis, 1 scarlet fever, and 1 Vincent’s angina. Sixty-six cases (40 per cent) showed hemolytic streptococcus in the throat at time of admission and were sent to the streptococcus wards; 99 cases (60 per cent) were negative for hemolytic streptococcus on admission, and of these 91 were sent to the “clean” influenza wards. Twenty-four of these clean cases subsequently became positive for S. hemolyticus. It is especially noteworthy that 14 of them acquired a hemolytic streptococcus during the short period that they were held in the receiving ward awaiting the report of the culture taken at time of admission, the first culture taken shortly after admission to the “clean” wards being positive. This result was undoubtedly due to the fact that these cases were unavoidably associated in the receiving ward with many carriers of hemolytic streptococcus. It is evident that cases which were supposedly free from streptococci but which in reality had picked up the organism in the receiving ward were constantly being sent to the “clean” wards. It is furthermore evident that if the precaution had not been taken of reculturing all clean cases on day of admission to the “clean” wards and daily thereafter these wards would soon have become saturated with hemolytic streptococci. Even under these conditions, 10 cases, after varying periods in the “clean” wards, acquired the organism in their throats. When it is stated that it required the full time of two men under very special conditions to carry out this work in a very limited number of cases and that it failed to keep “clean” wards free from hemolytic streptococci, it is only too apparent that the efficient separation of carriers from noncarriers in the presence of an epidemic of influenza is an impossible task.
The segregation of pneumococcus pneumonias following influenza according to type of infection is obviously impossible, since they are caused by an almost unlimited variety of immunologic types as far as present knowledge goes.
Even the efficient separation of streptococcus pneumonias from pneumococcus pneumonias would require a considerable team of workers and the closest cooperation between laboratory and ward staffs, so that no case of pneumonia would be sent to a pneumonia ward until the bacteriologic diagnosis had been made. In our experience this is rarely considered feasible even under ordinary conditions, and in the presence of an epidemic is nearly impossible because of the volume of work involved and the delay necessitated by bacteriologic methods. It is, nevertheless, absolutely essential if highly fatal ward epidemics of streptococcus pneumonia are to be prevented.
In view of the considerations discussed above, it is believed that the clear and most fundamental indication for the management of epidemic respiratory diseases in the army is to scatter patients as widely as possible instead of following the time-honored custom of concentrating them. In brief, abandon open ward treatment and adopt effective individual isolation of every case, maintaining as strict a quarantine as is demanded in other highly contagious and infectious diseases. The adoption of a strict aseptic technic in the handling of these patients is an evident corollary. Only by this means can the serious and highly fatal secondary hospital infections, which occur in influenza and pneumonia when these diseases are present in epidemic form, be prevented.
The prevention of secondary infection, prior to admission to the hospital, is another and more difficult problem. That opportunity for secondary contact infection in cases of influenza before patients reach the hospital is great seems unquestionable, since many cases have already developed these infections at time of admission. During the epidemic patients were crowded in regimental infirmaries, in ambulances, and in the receiving office of the hospital with every opportunity for droplet infection present. No study has been made of this question, but it seems reasonable that the same methods of prevention should apply, namely, effective separation of patients.
It is not within the scope of this paper to discuss details of method, but anything that is possible becomes feasible as soon as sufficient evidence can be brought to bear that it is a necessity. In the present instance it would seem that any means that can be used to reduce materially the terrific toll taken by respiratory diseases is an absolute necessity.
Summary
1. Secondary contact infection with pneumococci not infrequently occurs in patients with pneumonia following influenza when they are treated in hospital wards.