Читать книгу Epidemic Respiratory Disease - Thomas M. Rivers - Страница 24

Table of Contents

The foregoing studies have shown that hemolytic streptococcus infection may spread by contagion throughout an entire ward with great rapidity. Other observations have demonstrated that pneumococcus infection may be transmitted in the same way. Only three instances of this nature will be cited. The first occurred in Ward 3 (Table XXI). Between September 6 and 16 no cases of pneumonia caused by Pneumococcus Type II had been admitted to the ward. On September 16 Pvt. Swain was admitted to the ward and placed in Bed 3. Bacteriologic examination of his sputum showed that his pneumonia was caused by Pneumococcus Type II. At this time Pvt. Pullam, who had been admitted to the ward on September 9 with a pneumococcus Type IV pneumonia, occupied Bed 5 separated from Bed 3 by one intervening bed. He had had his crisis on September 14 and was doing well, his temperature being normal. On September 24 he developed a second attack of pneumonia and died on September 30. Cultures at autopsy showed Pneumococcus Type II in heart’s blood and lung, Pneumococcus Type II and B. influenzæ in the right bronchus. Pvt. Wolfe was admitted to the ward with bronchopneumonia on September 17 and placed in Bed 6 next to Pvt. Pullam. Pneumococcus Type IV and B. influenzæ were found in his sputum. His temperature had fallen to normal by lysis on September 21 and he was doing well. On September 23 his temperature suddenly rose and he developed a second attack of pneumonia. Pneumococcus Type II was isolated by blood culture on this date. He recovered. In both instances Pneumococcus Type II was acquired after the admission of a patient with a Pneumococcus Type II pneumonia, the opportunity for contact infection having been favored by the association of these patients in adjoining beds.

Table XXII
Secondary Infection with Pneumococcus Type II
NAME	BED OCCUPIED	ADMITTED	PNEUMOCOCCUS IN SPUTUM ON ADMISSION	SECONDARY INFECTION
DATE	PNEUMOCOCCUS AT AUTOPSY
Pvt. Smith	No. 26	Sept. 18	II		II
Pvt. Thompson	No. 28	Sept. 17	Atyp. II	Sept. 21	II
Pvt. Linehan	No. 30	Sept. 16	IV	Sept. 26	II

The second instance is almost identical and occurred on the opposite side of Ward 3 at about the same time (Table XXII). Pvt. Linehan was admitted on September 16 and placed in Bed 30. Pneumococcus Type IV was found in his sputum. Pvt. Thompson was admitted the following day with a Pneumococcus II atypical pneumonia and placed in Bed 28. The next day Pvt. Smith was admitted and placed in Bed 26. Pneumococcus Type II was found in his sputum. On September 19 Pvt. Thompson recovered by crisis and was doing well. On September 21 he had a chill, his temperature rose to 104.4° F. and he developed a second attack of pneumonia. He died on September 29; cultures at autopsy showing Pneumococcus Type II in heart’s blood and left pleural cavity, Pneumococcus Type II and B. influenzæ in bronchus and lung. Pvt. Linehan had begun to improve on September 24 and his temperature was falling by lysis. On September 26 he became worse, developed signs of pericarditis and died on September 30. Cultures from lungs and bronchus at autopsy showed Pneumococcus Type II and B. influenzæ. In both instances the fatal secondary infection with Pneumococcus Type II was undoubtedly acquired from Pvt. Smith in the nearby bed.

The third instance occurred in Ward 8 (Table XXIII). Pvts. Lewis and Scott were admitted on September 21 and were placed in adjoining beds, 50 and 51. Lewis showed Pneumococcus Type I in his sputum, Scott Pneumococcus II atypical. The following day Pvts. Pighee, Jones, and Columbus were admitted and given Beds 48, 49 and 53 respectively. All showed Pneumococcus II atypical in the sputum. Pvt. Lewis with Pneumococcus Type I pneumonia recovered by crisis on September 29. His temperature remained normal until October 2 when it suddenly rose to 104.2° F. He developed a second attack of pneumonia and died on October 8. Cultures at autopsy from heart’s blood and lung showed Pneumococcus II atypical, from the bronchus Pneumococcus II atypical and B. influenzæ. It is, of course, impossible to say from which one of his neighbors Pvt. Lewis acquired his second pneumococcus infection.

Table XXIII
Secondary Infection with Pneumococcus II Atypical
NAME	BED OCCUPIED	ADMITTED	PNEUMOCOCCUS IN SPUTUM ON ADMISSION	SECONDARY INFECTION
DATE	PNEUMOCOCCUS AT AUTOPSY
Pvt. Pighee	No. 48	Sept. 22	Atyp. II
Pvt. Jones	No. 49	Sept. 22	Atyp. II
Pvt. Lewis	No. 50	Sept. 21	I	Oct. 2	Atyp. II
Pvt. Scott	No. 51	Sept. 21	Atyp. II
Pvt. Columbus	No. 53	Sept. 22	Atyp. II

It is noteworthy that these instances of secondary contact infection with pneumococci occurred in wards where every precaution was supposedly taken to prevent transfer of infection from one patient to another. It is true however that the wards were greatly overcrowded at the time. Many other instances of secondary pneumococcus infection in cases of pneumonia following influenza were encountered in which it was impossible to trace the source of infection, many combinations of different types of pneumococcus being found. There were two instances in which Pneumococcus Type IV was found in the sputum by inoculation of white mice shortly after onset of pneumonia, whereas secondary infection with other types was found at autopsy, one with Pneumococcus Type II, one with Pneumococcus Type III. In 2 cases by inoculation of white mice, two types of pneumococcus were found simultaneously in the sputum coughed from the lung, in one Pneumococcus Types III and IV, in the other Pneumococcus Types I and IV. There were 5 cases in which two types of pneumococcus were found in cultures at autopsy as shown in Table XXIV. Combined pneumococcus infections of this nature are almost never encountered in pneumonia occurring under normal conditions in the absence of epidemic influenza.

Table XXIV
Mixed Pneumococcus Infections in Pneumonia
NAME	CULTURES AT AUTOPSY
HEART’S BLOOD	BRONCHUS	LUNGS
Pvt. Gal.		Pn. Type III	Pn. Type III
		B. influenzæ	Pn. Type IV
		Staphylococcus	B. influenzæ
Pvt. Sug.	Pn. Type III	Pn. Type III	Pn. Type III
		Pn. Type IV	Pn. Type IV
		B. influenzæ	B. influenzæ
		Staphylococcus
Pvt. Hig.	S. hemolyticus		Pn. Type II
			Pn. Type IV
			S. hemolyticus
			Staph. aureus
Pvt. Can.	Pn. Type I		Pn. Type III
			S. hemolyticus
Pvt. Fer.	Sterile	Pn. Type IV	Pn. Type I
		B. influenzæ	Pn. Type IV
		Staphylococcus	B. influenzæ

The foregoing data show that infection with one type of pneumococcus may readily be superimposed upon or closely follow infection with another type. Cases have been cited in which it was clearly demonstrated that this was due to contact infection. It is furthermore evident that pneumonia caused by one type of pneumococcus affords no reliable immunity against pneumonia caused by another type. The same conditions that favored the spread of hemolytic streptococcus infection also favored the transfer of pneumococcus infection from patient to patient.