ymS* ** <* THE INFLUENZA BACILLUS IN PAEANASAL SINUS INFECTIONS By S. J. Ceo we and W. S. Thackee-Neville, Baltimore (From the Departments of Surgery and Pathology of The Johns Hopkins Medical School.) [From Thi: .Toxins Hopkins Hospital Bulletin, Vol. XXX, No. 343, November, 1919J THE INFLUENZA BACILLUS IN PAEANASAL SINUS INFECTIONS By S. J. Crowe and W. S. Thackee-Neville, Baltimore (From the Departments of Surgery and Pathology of The Johns Flopkins Medical School.) There is some difference of opinion as to the nature of the [322] organism primarily responsible for the influenzal epidemic of 1918-1919. Pfeiffer's bacillus was found in a sufficient number of cases to raise the question as to whether it was the primary agent, or, like the streptococcus and pneumococ- cus, a secondary invader. We were interested to determine whether or not this bacil- lus occurred more frequently in a series of infected nasal sinuses observed immediately following the epidemic, than in a series of such cases observed during a period when there was no epidemic. During the height of the epidemic in Balti- more, it was impossible, owing to the press of work, and the scarcity of skilled help, to make bacteriological examinations of the infected sinuses. Within six weeks after the epidemic had subsided, however, one of us (Neville) undertook a care- ful bacteriological study of every case of maxillary sinus infection treated at The Johns Hopkins Hospital. We limited our study to the maxillary sinus, because this cavity is the one most frequently affected, and because the material for [323] culture can be obtained from this situation with less risk of contamination than from the ethmoidal, frontal or sphenoidal cells. We present for comparison two series of cases. The first series of seventy includes every case of accessory nasal sinus infection treated at The Johns Hopkins Hospital during the years 1912-1918, in which we have a report on the cultures (D [323] made from the antrum.* Of these 70 observations, made dur- ing a period when there was no epidemic of influenza, Ave have lo cases in which the influenza bacillus Avas found in the antrum. The 30 cases of the second series were all observed during February, March and April of 1919. In eight of these cases Ave found B. influenza in the antrum. It is of interest that the percentage of cases in which the influenza bacillus was found in the antrum is about the same in each group. The material for culture is obtained by a very simple method. A small piece of cotton on the end of a steel appli- cator is moistened with a 20 per cent solution of cocaine and 1: 1000 adrenalin. The excess of cocaine is removed by pressing the cotton between two layers of gauze; this will insure against symptoms of cocaine poisoning. A small piece of cotton moistened with cocaine and adrenalin is also placed between the anterior end of the inferior turbinate and the septum, and both are left in place for ten or fifteen minutes. A curved trochar, a small rubber ear syringe, a nasal speculum and a finger boAvl are then boiled for at least five minutes. The patient's nose is cleansed of all visible discharge. The trochar is passed under the anterior end of the inferior tur- binate into the antrum, and the stilette removed. The patient bends 90° forward, and often the pus will drop from the cannula. If not, air or a few drops of sterile salt solution are blown into the antrum with the rubber syringe, and the material returning through the cannula is caught in a sterile test-tube. It is important that enough adrenalin be used to make the procedure absolutely bloodless, for Ave have found, in agreement Avith Rivers, that a feAV drops of blood mixed with the material obtained for culture will inhibit the growth of the influenza bacillus.1 The bacteriological technique employed is as foIIoavs : The material is plated immediately on agar containing defibri- * It was formerly our custom to take cultures from infected sinuses (chiefly at operation) on cotton swabs. These swabs were sent to the regular bacteriological laboratory of the hospital but had often completely dried up before reaching the laboratory. This accounts for the comparatively small number in which we have a bacteriological report. (2) nated rabbit's blood, and the plates are incubated at 37° C. [323] for twenty-four hours. The various colonies are then ex- amined in stained smears and transferred to blood-agar slants. After twenty-four hours the colonies showing the cultural characteristics of the streptococcus and pneumococcus are dif- ferentiated by Neufeld's bile soluble test. The pneumococci are grouped according to the method of Avery, Chickering, Cole and Dochez.2 The serum used was obtained from the Rockefeller Institute. The influenza bacillus grows freely on blood-agar but not at all on plain agar. This differentiates it from the micrococcus catarrhalis. This latter organism may be differentiated from other gram-negative cocci by the use of Hiss's serum sugar media, and the Elser and Huntoon classification.' In the first series of 70 cases observed during the period from 1912 to 1918, the influenza bacillus was found in the antrum in 15 cases (21 per cent). The streptococcus was found in 33 cases (47 per cent) ; in 10 of these the organism was haemolytic. The pneumococcus occurred 12 times (17 per cent). The staphylococcus was found in 16 cases (22 per cent), in one of which it was haemolytic; the proteus was found once; and the diphtheria bacillus twice. In the second series of 30 cases observed during the three months immediately following the subsidence of the influenzal epidemic, the influenza bacillus was found in the antrum in eight cases (26 per cent). The streptococcus was again the predominating organism (14 cases, or 46 per cent); of these 14 cases, in four it was haemolytic. The following organisms were occasionally found: the haemolytic staphylococcus in four cases, the pneumococcus in three cases, the micrococcus catarrhalis in two cases, and a gram-negative diphtheroid bacillus in three cases. The diphtheria bacillus was found in one case, the bacillus lactis aerogenes once, and the proteus vulgaris in two cases. The influenza bacillus was recovered from the antrum in pure culture in four cases. In four other cases it was found associated with other organisms: streptococcus hsemolyticus, streptococcus mucosus, micrococcus catarrhalis, micrococcus tetragenus, and the staphylococcus albus. The haemolytic (3) [323] staphylococcus occurred four times, once in pure culture. The staphylococcus albus was found in eight cases, but was prob- ably in each case a contamination from the nasal cavity.f The pneumococcus was recovered in three cases (in two Type III and in one Type IV), twice in pure culture, once mixed Avith a staphylococcus albus. [324] CONCLUSIONS 1. The influenza bacillus Avas found in infected maxillary sinuses in practically the same percentage (21 per cent) in a series of cases observed during a period of six years Avhen there Avas no epidemic, as in a second series observed im- mediately following the epidemic in Baltimore during the winter of 1918-1919 (26 per cent). 2. The influenza bacillus is not infrequently found in pure culture in the antrum. 3. Clinically B. influenza is a pyogenic organism. 4. The predominating organism in all antrum infections is the streptococcus. 5. We infer from these observations that the influenza bacil- lus, like the streptococcus and pneumococcus, is a secondary [323] t The healthy nasal cavity is apparently a normal habitat for the staphylococcus albus. We took cultures from the middle turbinate in seven individuals with clinically normal nasal cavi- ties. A little mucus was obtained from the middle turbinate with a platinum loop and implanted on plates of rabbit blood- agar. We found: staphylococcus albus 91 per cent; diphtheroids, 41 per cent; pneumococcus, Type IV, 16 per cent; micrococcus catarrhalis, 8.9 per cent. Park and Wright, in 1898, took cultures with a platinum loop from far back in the nose and showed that the nasal secretion has no bactericidal action. Of 36 examinations only six were sterile. The predominating organism was the staphylococcus. Hasslauer3 in 1902, made bacteriological examinations from the normal nasal cavities of 111 individuals. He found: staphylo- coccus in 25 per cent; pneumococcus in 20 per cent; streptococcus in 17 per cent; diphtheroid in 13 per cent. He also investigated the bacteriological content of the nasal discharge in 78 cases with a coryza and found much the same varieties of organisms in both healthy and pathological nasal cavities. The only difference was that they were far more numer- ous in infected nasal cavities. (4) invader, and .not the primary cause of the disease known as [324] influenza. LITERATURE 1. Rivers, T. R.: The effect of different bloods on the growth of B. influenza;. Johns Hopkins Hosp. Bull. Balto., 1916, XXX, 129- 131. [B. influenzw grows better on rabbit blood- and cat blood-agar than on human blood-agar; and defibrinated human blood and normal human serum are very bactericidal for the strains of influenza bacillus studied as compared with defibrinated rabbit blood, normal rabbit serum and normal guinea-pig serum.] 2. Avery, Chickering, Cole and Dochez: Acute lobar pneumonia. Monogr. Rockefeller Inst. M. Research, N. Y., 1917, No. VII, p. 25. 3. Hasslauer, W.: Die Bakterienflora der gesunden und kranken Nasenschleimhaut. Centralbl. f. Bakteriol., 1. Abt., Jena., 1902, XXXIII, 47-51. Gibson, G. H., Bowman, B., and Connor, J. I.: Etiology of in- fluenza, Brit. M. J., Lond., 1919, I, 331-335. [The influenza epidemic was due to a minute flltrable microorganism of coccoid shape grown by Noguchi's cultural methods.] Lewis, C. T., and Turner, A. L. Suppuration in the accessory sinuses of nose: a bacteriological and clinical research. Edin. M. J., 1905, n. s., XVIII, 395-421; ibidem, 1910, n. s. IV, 293-318. [In 43 antral cultures taken without reference to an influenza epidemic the influenza bacillus was recovered three times. In another series of 57 cases it was recovered once. In both series streptococcus, pneumococcus and staphylococcus were the chief organisms found.] MacCallum, W. G.: The pathology of the pneumonia in the United States army camps during the winter of 1917-1918. Monogr. Rockefeller Inst. M. Research, N. Y., 1919, No. X, 140. [Of 48 cases of pneumonia of influenzal origin 16 contained the influenza bacillus in the bronchioles and occasionally in the alveoli. In six other cases the B. influenzw was found in the sputum.] (5> \