Epidemic Respiratory Disease / The pneumonias and other infections of the repiratory tract accompanying influenza and measles

by Eugene L. Opie; Francis G. Blake; Thomas M. Rivers; James C. Small

In comparing men arriving at the hospital acutely ill with measles with normal men in the organization from which they came, only one variable can be found on which to base the differences observed in the two groups. This is the advent of the acute disease. The figures seem to suggest a temporary disappearance of hemolytic streptococci from the throats of patients acutely ill with measles, at least, to such an extent that the same cultural methods fail to identify the organisms.

The increase in the S. hemolyticus carriers among patients with measles after a period in the hospital might depend upon two factors: First, the exposure to contact infections in the hospital ward, depending on the length of time in the ward as well as on the character of the ward management; second, the passing of the acute stage of measles with a return of the bacterial flora of the throat to the condition existing before the onset of the acute disease. The first appears the more probable. The second has only the support of the observation that the streptococci were absent from the throat during the acute stage of measles or were much less frequently found in patients with measles than in normal men and later their incidence approached that in normal individuals. The rather high incidence of hemolytic streptococci in normal men at Camp Funston may have been due to the very recent assembling of the 10th Division which now occupied the camp. It is probable that the housing of large numbers of men in barracks is attended by the same contact dissemination of mouth organisms that occurs in hospital wards.

Measles at Camp Pike.—All cases of measles coming into the base hospital at Camp Pike between September 15 and December 15, 1918, a total of 867 cases, are included in the report. Upon the arrival of the commission at Camp Pike early in September, a plan for the separation of cases carrying hemolytic streptococci and those free from these organisms was put into operation. The preliminary arrangements included the allotment of suitable wards for treatment of the different classes of cases; a throat culture survey of all patients with measles under treatment at the time; their separation in accordance with the results of bacteriologic examination, and the transfer of each group of patients to its designated ward. By September 15 these preliminary arrangements had been completed. Cases of measles admitted on this date and afterwards were held in an observation ward pending the report upon a throat culture before they were transferred to the treatment wards.

Beginning September 15 the following system of handling measles cases was maintained in the wards of the base hospital.

All patients were received in an observation ward where they remained until the results of a throat culture for hemolytic streptococci could be reported back to the ward. Cases reported positive or negative were immediately transferred to their respective treatment wards. All patients in the treatment wards were cultured at intervals of one week and cases found positive were transferred from the “clean” treatment wards to a treatment ward for cases carrying hemolytic streptococci. The ward personnel attending patients in the “clean” treatment wards was examined by throat cultures from time to time with the purpose of eliminating S. hemolyticus carriers. Patients segregated in the streptococcus wards remained there, if uncomplicated, throughout their hospital treatment even though subsequent repeated throat cultures showed that the carrier condition had disappeared. Two wards were provided to care for the pneumonia following measles. One received only patients whose throat cultures were negative for hemolytic streptococci; the other, those positive. It is essential that the throat culture on which this differentiation is made be taken as soon as the complication is reported and that transfer be made promptly on receipt of the report of the culture. To facilitate this transfer, cases of pneumonia complicating measles were reported to the laboratory as soon as diagnosed and cultures were taken at once. The case remained in the measles ward during twenty-four hours, isolated as well as possible, awaiting report of culture before transfer. Within the positive ward for measles pneumonias, distinction was made between streptococcus pneumonias and nonstreptococcus pneumonias harboring hemolytic streptococci in their throats. The two classes of cases were treated in separate sections of the ward.

Ear complications were seen and treated by medical officers from the otological service. These patients remained in the measles wards while in the acute stage of measles, but later were transferred to the service of otology whenever further surgical treatment became necessary.

Within the individual wards for treatment of measles and measles pneumonias, precautions for minimizing the dangers of contact infections were carried out as well as possible. Throughout the study we had the hearty cooperation of the base hospital authorities and earnest, well-directed effort to perfect ward management on the part of the ward surgeons and their staffs. Difficulties encountered during the emergency created by the sudden explosion of the influenza epidemic, in spite of the best efforts of all, did much to disrupt the plan which had been instituted for the control and study of the complications of measles. Scarcely had wards been designated and all measles patients on hand differentially allotted to them, when the influenza epidemic appeared and quickly filled the hospital beyond its capacity. Measles wards were taken over for the care of influenza patients. Measles patients, of which there were not a great number at the time, were necessarily crowded together, so that compartments of wards instead of separate wards had to be used in maintaining our separation of the two groups of patients. While the base hospital was yet filled with patients with influenza and influenza pneumonia, admission of patients with measles increased, so that one ward after another was reclaimed for the care of this disease. During this period the measles wards were at times overcrowded and the strictest ward technic could not be practiced. Again new wards were, on occasions, partly filled by admission and transfer before they were properly equipped to receive patients. This disorganization was directly due to the necessity of treating a rapidly increasing number of measles patients before the hospital was cleared of patients with influenza and pneumonia. After this emergency, the system of ward management was rapidly readjusted, and admissions were limited to the normal capacities of the wards.

The cubicle system was used in all wards. Bed patients were not required to wear masks, but the mask was strictly enforced upon all patients leaving the cubicle. All attendants were required to wear gowns, caps and masks while in the wards. An attempt was made to prevent the congregating of convalescents. Guards were posted at the latrine doors to limit admission to the capacity of the latrine. Borrowing and lending of any materials between patients were strictly forbidden. Paper sputum cups were provided, kept clean and covered. In the measles pneumonia wards hand disinfectant solutions were provided for use by attendants when they passed from one patient to another. The ward floors were scrubbed at intervals with lysol in water. Dry sweeping of the wards in the morning is regrettable.

Bacteriologic Methods Used in the Study.—The methods used for the identification of hemolytic streptococci here were essentially the same as those used at Camp Funston and described above, the one exception being the use of surface cultures on blood agar instead of the combined surface and deep culture. Blood agar plates containing 5 per cent defibrinated horse blood were poured and used while fresh. The throat swabs were carried to the laboratory in sterile test tubes. The plates were inoculated by touching the swab lightly to the surface of the agar plate at two places, one near either extremity of a given diameter of the plate. On touching the swab to the agar, the swab stick was rolled between the fingers so as to turn it through one revolution and thereby bring all points of the circumference of the cotton swab in contact with the agar surface.

The material thus inoculated on the plates was spread by means of a platinum wire slightly turned over at the end in “hockey stick” fashion. The wire was passed back and forth several times over the point of inoculation and then multiple streaks and cross streaks were made over the agar surface. The initial contact of the wire with the point of inoculation was not repeated. The cross streaking serves to spread and distribute this material evenly over the surface. Well seeded plates by this multiple streak method are the rule and the uniform distribution of well separated colonies over the surface makes it very easy to pick pure cultures, and renders plate reading easy.