Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 155

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 155

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BIBLIOGRAPHY.

1. Annual Report of the Sub-Department of Health for the Baltimore for the year 1907, p. 44.

2. Conn: Med. Rec., 1894, XLVI, 743.

3. Buchan: J. Hyg., 1910, X. 569.

4. Baetjer: Johns Hopkins Hosp. Bull., 1909, XX, 152.

5. Levy and Freeman: Old Dominion J. M. and S., 19 315, 411.

6. Jackson: Pollution of New York Harbor as & Mt Health by the Dissemination of Intestinal Diseases t ... the Agency of the Common House Fly. A Report by B. Jackson to the Committee on Pollution of the Mer. Association of New York.

The House Fly at the Bar. Indictment. Guilty or not ... The Merchants' Association of New York, July, 1905.

7. Ford: Johns Hopkins Hosp. Bull., 1911. XXII, 53.

8. Stokes and Hachtel: Arch. Int. Med., 1910, VI, 121. Google

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HOSPITAL AND MEDICAL SCHOOL: GENERAL PROCEDURES ADOPTED .*

By WILLIAM W. FORD, M. D., D. P. H., Associate Professor of Hygiene and Bacteriology, The Johns Hopkins University.

ing the last week in January and the first two weeks of try of this year (1911) a number of cases of diphtheria ed in the Johns Hopkins Hospital and Medical School. nuary 25, a pupil nurse with the disease was admitted Isolation Ward, and on February 3 a patient in the ward, Ward F, developed clinical symptoms of diph- and a throat culture showed the Klebs-Loeffler bacillus. s immediately isolated and no further cases appeared at me in the ward from which he was taken. On February upil nurse in charge of the children in Ward G, the and children's ward, developed diphtheria and on the ng day an employee in the baggage room was found 1 infected throat. These cases all presented the clinical : of a mild type of the disease and rapidly recovered. bruary 11, a child in Ward G, an old burn and skin- g case, exhibited a bloody nasal discharge. It had been and ailing for some time and the attention of both and nurses had been directed to its condition. When charge appeared it was at once examined and the di- . of nasal diphtheria established. This infection proved irulent in character, the child dying, despite the vigor- : of antitoxin. It had evidently had the disease several fore clinical symptoms were noted. No idea that the on would spread was then entertained, but on February more cases developed in children in the same ward, }, and two days later a fourth-year student on duty as cal clerk in this ward was found infected with the eristic organism. In a period of twenty-two days eight : the disease had thus made their appearance, five of cated in Ward G, three in children patients and two in ials rendering assistance in the care of these patients. number of cases of diphtheria was by no means out ordinary, either for large general hospitals of the size Johns Hopkins or for this Hospital itself. We have had an occasional Klebs-Loeffler infection and shall expect such sporadic cases. We live in a community iphtheria is ever present, and the extension of the out- ection to the Hospital is never unexpected, nor is it a matter of concern. But when the Clinical Clerk on was found with the disease, and it was realized that her cases had developed in the children on the same was suspected that the infection might have spread ore or less systematic examination of patients, nurses lents in this ward was carried out. No cases were aght to light, but four days later another fourth-year n Ward G was found infected. This was on February

read at the 1911 meeting of the Interurban Clinical

20, and on the following day diphtheria was discovered in three adult patients in Ward G, in three nurses in this ward, in another nurse, a room-mate of one of the infected Ward G nurses, and in a nurse in the general operating room, who had handled Ward G patients.

This more or less sudden outbreak of diphtheria in Ward G, or rather this sudden spread of the contagion, was viewed with great uneasiness by the medical internes and especially by the Resident Physician, Dr. Sladen, and by Dr. Austrian, who had been examining the cultures. The occurrence on one day of eight cases of diphtheria associated with one ward indi- cated a firmly seated focus of infection and a by no means remote possibility that this infection would spread in a num- ber of directions. The very free access to the wards which our students enjoy added to the body of patients, doctors, nurses and attendants who might become infected, another fairly large and somewhat widely distributed group of indi- viduals who could carry infection to various points. Actuated by a well justified concern, on February 21, after these eight cases of diphtheria were discovered, the Resident Medical Staff instituted a systematic examination of the hospital population. The throats of all were carefully studied for local signs of in- fection, and on the slightest appearance of suspicious symptoms the individuals were segregated and cultures taken. The fol- lowing day three more cases of diphtheria were brought to light, an adult patient, a nurse in Ward G and a medical interne in another ward. On Thursday, February 23, seven cases were discovered, two more children in Ward G, three nurses and a member of the second-year medical class. On Friday, February 24, eleven cases of diphtheria made their appearance, two more nurses, a patient in Ward F and eight medical students.

At this time the situation was regarded as extremely seri- ous by all the men who were working on the wards. Cases of the disease were cropping out with great rapidity and in a number of different areas. It was evident that diphtheria had gotten a firm foothold in the institution. From January 25 to February 25 thirty-eight cases had developed. This was despite the fact that the cases were recognized early, the diagnosis established soon after the appearance of clinical symptoms, complete isolation of all the patients carried out and energetic cleaning and disinfection employed to rid the infected localities of the contagious material. In brief, all the measures which under ordinary circumstances are employed to prevent the spread of the Klebs-Loeffler bacillus had been adopted and yet the disease was steadily increasing in inten- sity. The occurrence on two days of eighteen cases of diph- theria was too serious a matter for both the Hospital and the

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Medical School not to be regarded with considerable uneasi- ness. It was furthermore clear that the disease was spreading in two directions, independently and simultaneously : first, in the group of persons associated with Ward G, patients, nurses and assistants, and individuals in the Nurses' Home, who had been in contact with the Ward G nurses; and, secondly, in the student-body of the Medical School. In regard to the first group of people two possibilities existed, one that a focus of diphtheria existed in Ward G, from which source it spread to the Nurses' Home, the other that a focus existed in the Nurses' Home, from which point it spread to the patients in the ward. In the second group, the medical students, cases had been discovered in all the classes and the appearance of a greater number in the first- and second-year students, who do not come into the hospital, than in members of the third- and fourth-year classes, who might be infected from ward cases, was a proof of the independent transmission of the disease among the students themselves. Various avenues by means of which the infection might be spreading in the student-body were suggested, the most probable channels being the Lunch Room in the basement of the Physiological Building, where about a hundred men and women from all four classes take their midday meal, and the various students' clubs and board- ing houses.

At the meeting of the Advisory Board of the Medical Fac- ulty on Friday, February 24, the many details of the situa- tion were presented by Dr. Barker, and it was decided to close the Medical School. A committee was appointed to take charge of the situation. This committee, known after- wards as the Diphtheria Committee, consisted of Dr. Williams, Dr. Barker and Dr. Ford. Dr. Norton was asked to become an ex-officio member as the Acting Superintendent of the Hos- pital. It should be mentioned that only by the active and willing co-operation of Dr. Norton with this committee was it possible to carry out the various measures which were sug- gested to stamp out the disease. To the Diphtheria Committee all questions relative to the epidemic in both Hospital and Medical School were referred.

On Saturday morning, February 25, Dr. Williams, the Dean of the Medical School, posted notices stating that the insti- tution was closed temporarily. Later notices were sent to all the students urging them to remain in Baltimore, to keep in close touch with the school authorities and to avoid appearance in public places like theaters and churches. On the same morning the Diphtheria Committee held its first meeting. The various features of the epidemic were discussed at length and certain general measures were decided upon. These measures . included the further examination of all the Hospital inmates, patients, doctors, nurses, orderlies, etc., the taking of routine throat cultures from all the medical students, and the clean- ing and disinfection of the medical buildings. An investiga- tion into the conditions of the many boarding houses where the students live, to bring to light any hidden foci of infection, was also considered advisable, and Dr. W. L. Moss was asked to undertake this latter work.

At this time it was deemed of great importance to close touch with the Department of Health of the ('- Baltimore, and Dr. Moss and Dr. Ford, at the request" committee, had a long conference with Dr. Jones, Az: Commissioner of Health. At this conference a nz plans of work were considered. Dr. Jones suggested : the importance of taking throat cultures from all the _ of the students' boarding houses to determine whether : fection was spreading or likely to spread to the city. 5 the resources of the Health Department at the service : Moss in his investigation and made him a temporary of the Department. Dr. Jones expressed his great de co-operate with the Diphtheria Committee in any way pe. and all questions affecting the relationship of the Hoe ;. the city, such as the discharge of patients, were there' ... mitted to him for decision.

On Saturday, February 26, six additional cases of dp -. developed and on the following Sunday eight more, :- members of the Faculty or their families. When t: mittee met on Monday fourteen cases had thus been & .. the thirty-eight already reported, making a total of #5; It was evident that the disease was spreading rapidly was therefore decided to close the Dispensary, partly = to give it a thorough overhauling, and to admit t : patients to the Hospital except certain urgent cases ;"; to be warned of the danger.

By this time the various measures of cleaning and . fection, of taking routine cultures from the thratte .. Hospital and Medical School population, the complete is of individuals with positive throat cultures, the detect suspects, had. been put in operation. It was appari." some of the patients were rapidly recovering and suck .. be ready for discharge. A number of non-infected p were also anxious to leave the Hospital. Dr. Jones was fore appealed to, for a ruling in regard to the maite. decided that the patients should be divided into three : and treated as follows: First, all persons who had re: from diphtheria could be discharged when two neprir. tures from nose and throat separated by a forty-eight: interval had been obtained. Secondly, all persons ery .. diphtheria and not contracting the disease could be dis. when one negative nose and throat culture had been city. Thirdly, all persons not exposed to the disease coule when one negative throat culture had been secured. 3 upon these rulings on Tuesday, February 28, Dr. M posted notices in the Hospital and began the dischar: patients.

The cleaning and disinfection of the Medical Bui .... put in charge of the writer and presented a special :: which may be considered briefly. The buildings af: "; divided into many rooms, devoted to all sorts of purp .*- were in active use at the time of closure. The pres. large corridors and stairways, establishing a free com. tion often between basement and attic seemed to re2." gaseous fumigation valueless. Largely upon the adr. -

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Lager ways wanegut of about six feet, after the build- had been allowed to rest absolutely undisturbed for 24 to ours to allow the dust to settle. Attempts which were to disinfect some of the rooms with formaldehyde gas ned from such preparations as briquets of formanganate patent candles which on burning evolve this vapor, nstrated the uselessness of the procedure. In a few min- after the evolution of the gas had been brought about the of it had disappeared from the rooms, the many open- about the doors and windows, the heating apparatus, and entilating shafts, permitting it to pass into other parts : building. It was evident that some method of obtaining tinuous evolution of the gas lasting a number of hours be hit upon if an effective disinfection of these large ings was to be obtained. At the suggestion of Mr. ey, head janitor of the Anatomical Laboratory, this t was accomplished by the long-continued boiling of ons of 40% formalin in water in the proportion of about art to three. The windows and doors of the buildings tightly closed, all the inside doors leading from the ; to the corridors opened and saucepans containing the ilin mixture were boiled over Bunsen burners in a num- f different localities. A constant evolution of the gas g six to eight hours was thus obtained, the atmosphere › building being saturated with the vapor for a consider- period of time. The flames of the Bunsen burners were guished by turning off the main supply of gas in the ment and on the following day the buildings were opened, ughly aired and the work of cleaning undertaken. The and walls were first washed with soap and water and viped off with some disinfectant solution, either a solution 'bolic acid or one of corrosive sublimate. Whenever the substance was used it was followed by another washing soap and water.

buildings where the presence of animals or expensive itus likely to be injured by the vapor of formaldehyde ited this disinfection of the structure as a whole, the te rooms were sealed up and fumigated by the Parke formanganate briquets or by the Du Prey candles. rooms were kept tightly closed for 24 hours and then ors and walls were washed with soap and water and isinfectants.

acteriological tests were made to determine the efficiency fumigation. The necessity for rapid work precluded tisfactory observations, and it was realized that no l of disinfection is perfect. It was decided to carry out rously as possible those methods which are recognized f the greatest value and to trust to a wise providence le contagion would be destroyed. Afterwards, when me was available, with Dr. Norton's help, a number of tions were made during the disinfection of Ward G. found that surface cultures of organisms like Bacillus is, Bacillus coli, Streptococcus pyogenes, and Bacillus asus were killed when exposed to the gas generated by

Special emphasis was placed upon the disinfection and cleaning of the Lunch Room in the basement of the Physiologi- cal Laboratory. From the beginning of the epidemic it was believed that it might be one of the main foci of infection among the students. Primarily it was the only place where there was a general meeting of the members of all classes. Again, certain practices in vogue there, such as cleaning the table-tops with napkins left by students who had already taken their lunch and departed, seemed to offer an abundant oppor- tunity for the spread of any contagious material coming from the throat. This room was therefore fumigated and washed thoroughly on two occasions separated by an interval of several days, and when finally reopened certain changes were insti- tuted in the care of the dishes and napkins.

The students were encouraged to disinfect their own rooms, and in many instances were supplied with material from a quantity of disinfectant which had been sent to the school from the Department of Health. In all the students' club- houses and in the majority of students' boarding houses this procedure was carried out most energetically.

Certain special difficulties were met with in the work of cleaning. In the first place it was extremely hard to get labor because of the widespread fear of diphtheria which had been engendered in the minds of the various residents in the vicinity of the Hospital, partly because of the wide publicity which had been given the epidemic by the newspaper reports. In the second place it was believed that all the people working in the buildings would be exposed to infection with the Klebs- Loeffler bacillus and the problem of their proper care had to be met. Eventually, a sufficient number of active people were obtained to do the necessary work. No cultures were taken from the throats of these individuals during their time of em- ployment. It was perfectly evident that if suspicion should arise that they stood in danger of infection under no circum- stances could they be induced to remain at work. At the same time it was realized that these individuals should be carefully examined at the end of the period of cleaning and disinfection to determine whether any of them had become infected with the diphtheria bacillus. This work in the medical buildings was completed in about a week from the time it was started. On Saturday, March 4, cultures were taken from all the work- people, the extra employees were discharged, and the control of the buildings turned over to the Dean of the school. One positive throat culture was found in a woman who had been working in the Physiological Laboratory. It was not absolutely certain that this woman became infected in this building, since we had no negative throat culture at the time she began her work there, but the presumption was in favor of this source of her contagion. This case proved to be of considerable interest and importance. The woman harbored diphtheria bacilli in her throat for a period of fully 20 days, during which time she had no clinical symptoms or signs whatever. All sorts of measures were carried out to rid her throat of the organisms, such as spraying with various disinfectants and

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with antitoxin itself. She received as well the regular anti- toxin treatment administered subcutaneously. Eventually two negative cultures from her throat were obtained by the officials of the Health Department, and she was discharged from quar- antine. This was one of the few definite cases in this epidemic where the diphtheria bacillus remained for some time in the throat of an individual without causing the appearance of clinical symptoms.

The most perplexing question which the Diphtheria Com- mittee had to decide was in regard to the use of prophylactic or immunizing doses of diphtheria antitoxin. This measure was discussed on a number of occasions. A large number, if not all, of the doctors and nurses in contact with the disease took this treatment soon after the epidemic broke out. It was a matter of great importance, however, to determine whether this procedure should be insisted upon with all the inmates of the Nurses' Home and with the members of the Resident Staff of the Hospital. The Health Department from the first had recommended prophylactic antitoxin as the only remedy which could be relied upon to stop the spread of diph- theria among the nurses. At the same time the administration of antitoxin is certainly followed in a few individuals by the appearance of disagreeable or untoward consequences and authorities are by no means agreed as to its value in checking epidemics. Relying upon several experiences in Baltimore where diphtheria has been stamped out of a number of institu- tions only when prophylactic antitoxin has been administered to all the inmates, upon reports from various hospitals for the care of contagious diseases in which this treatment is carried out as a routine measure with the children when diphtheria appears, and upon a number of publications as to the per- centage of bad results which follow the use of antitoxin, the committee decided to recommend but not to insist upon this measure. Whenever antitoxin had been administered pre- viously, wherever an authentic history of attacks of asthma could be elicited, contra-indications were recognized to the use of the remedy.

A careful record of the administrations of antitoxin was kept by Dr. Sladen and his staff. Over three hundred prophy- lactic doses were given, two hundred nurses receiving the treatment, forty-three students, and a small proportion of the resident staff. About seventy patients took curative doses of the remedy. Nearly all the individuals who received the anti- toxin either for prophylactic purposes or to combat an existing infection with the Klebs-Loeffler bacillus developed some local signs. In most cases the reaction was limited to slight urti- caria. In a few instances a pronounced œdema was noted with local tenderness and elevation of temperature in the dependent parts near the site of injection. In five cases char- acteristic serum disease appeared. In one of these cases, a fourth-year student, immediately following the injection of the antitoxin a typical anaphylactic shock developed with great dyspnœa, shivering, vomiting, and attacks of faintness with tendency to syncope. These symptoms lasted for a number of hour- ' ' eventually entirely disappeared. This student had

received antitoxin previously and gave a history of asthur: attacks in his youth. In the other four cases in but one c:3 instances had antitoxin been administered previously.

How far the prophylactic use of diphtheria antitonic instrumental in stopping this epidemic is not clear. It ber of interesting facts were noted which indicate that is :- did have a definite effect upon the spread of the disease. : only nurse in Ward G who refused antitoxin later derelbe diphtheria. Among the other nurses on this ward who revira the treatment no cases of infection appeared. Of the children in Ward G, all exposed to infection, four Tet. prophylactic antitoxin. Of these four, two later showed ?. tive cultures of the diphtheria bacillus, but had no k. symptoms. The two other children on Ward G, in wh: was not considered advisable to administer the antitoxin - cause of recent surgical operations, developed diphtheria lez and died. Coincidently with or immediately following general administration of prophylactic doses of antiter? : the nurses in the Nurses' Home, the infection disappeared : this group of individuals, and it did not disappear unt] :. measure was carried out. While thus no proof can be brea. to show that this procedure was operative in controlling t. infection, the majority of the men who administered the s toxin and followed the cases of diphtheria afterwards i convinced that it had no little influence in checking the : | demic. At the same time the prophylactic use of dipht'- antitoxin is probably the one measure adopted which [ .: not be carried out so vigorously should we have epidemics diphtheria to deal with in the future. While in our espe: ence no serious results developed from the use of this reme: there is a very general sentiment against it in both de" and nurses, and this feeling is undoubtedly justified br : observations which have been published.

On Friday, March 3, it was apparent that the epidemic v. dying out. From a case incidence of eight on the precel .:. Sunday, the number of cases had dropped irregularly du this week. Two cases in the nurses appeared on Monday .: cases were reported on Tuesday, three were found among : students on Wednesday, four cases developed on Thurs !: one student, one nurse, one ward doctor and one orderly, e: two came to light on Friday among the laundry emplete- Altogether but eleven had developed in five days, and the had such a varied distribution as to indicate that they w" but scattering cases at the end of a general epidemic. it: Friday, therefore, Dr. Williams sent notices to the stude: and instructors that the school would open again to the EN two years on Wednesday, March 8; to the last two years : the following day, at which time the dispensary was to opened again to the public. Cultures were taken from all # students and instructors and only those with negative rep" admitted to the school. The exercises began again on Weis- day and by the latter part of the week the routine of the Me cal School had been re-established in all the classes. The : fected wards of the Hospital were cleaned and fumigated. : patients who had recovered were discharged and new patz. again were received for treatment.

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Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 155

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189