VV/X &VV 'V  i i : : !Hi iiiii! i ' iillijpiiiiliill ........... .iiiii; MiMiii!: HOSPITAL BULLETIN No. 1 A Study of the Acute Anterior Poliomyelitis Epidemic which occurred in the City, of Buffalo, New York, U. S. A., during the Year 1912 PUBLISHED BY THE DEPARTMENT OF HEALTH BUFFALO, N. Y. FRANCIS E. FRONCZAK, M. D., HEALTH COMMISSIONER EDITED BY WALTER S. GOOD ALE, M. D., SUPT. OF HOSPITALSHospital Bulletin, No. 1. A Study of the Acute Anterior Poliomyelitis > > < Epidemic which Occurred in the City of Buffalo, New York, U. S. A., During the Year 1912. CONTRIBUTORS Simon Flexnfr, M. D., Director of the Rockefeller Institute for Medical Research, New York City. Wade H. Frost, M. D., Passed Assistant Surgeon, U. S. Public Health Service. James P. Leake, M. D., Assistant Surgeon, U. S. Public Health Service. Francis R. Fraser, M. D., Clinician, Hospital of the Rockefeller Institute for Medical Research, New York City. Nelson G. Russell, M. D., Consultant, Ernest Wende Hospital for acute communicable diseases, Department of Health, Buffalo, N. Y. Edward A. Sharp, M. D., Considtant, Ernest Wende Hospital for acute communicable diseases, Department of Health, Buffalo, N. Y. Walter S. Goodale, M. D., Superintendent of Hospitals, Department of Health, Buffalo, N. Y. BOARD OF HEALTH Hon. Louis P. Fuhrmann, Mayor. Col. Francis G. Ward, Commissioner of Public Works. Francis E. Fronczak, M. D., Health Commissioner. August Schneider, Secretary. BUREAU OF HOSPITALS Municipal Hospital, 770 East Ferry Street, for Chronic Tuberculosis (125 beds). Ernest Wende Hospital, Broadway and Spring Street, for Acute Communicable Diseases (150 beds).FOREWORD From January 1 to November 7, 1912, inclusive, there were reported to the Department of Health, Buffalo, N. Y., 335 cases of alleged acute anterior poliomyelitis. By various processes of elimination this number was reduced to 281 undoubted cases. These returns might well cause alarm to those entrusted with the administration of public health work in a city the size of Buffalo. While there are many acute communicable diseases numerically Stronger during the course of the year than poliomyelitis, there are few, if any, which leave behind such a large proportion of permanently maimed and disabled victims. So soon as the epidemic became manifest, rigid steps were taken to placard and isolate every reported case Occurring in the city. In addition, the Department of Health determined to make a rigid investigation of the outbreak, in the hope that some information might be elicited o'f value to our citizens particularly, and to the world at large generally. The study which ensued after this determination had been reached was perhaps the most far-reaching and comprehensive that, had ever been undertaken by the Department of Health in reference to any individual disease. This is especially noteworthy in view of the fact that the entire expense to the municipality is comprehended in the cost of this publication, a work which is but another monument to the unselfish devotion that has always characterized the medical profession. Words do fail and phrases grow meaningless as I thus attempt to thank the men whose labors made the publication of this pamphlet possible. That noble seat of learning, the Rockefeller Institute foT Medical Research, New York City, is represented by its Director, Dr. Simon Flexner, and o"ne of its Hospital Clinicians, Dr. Francis R. Fraser.4 Foreword Surgeon-General Rupert Blue, of the United States Public Health Service, detailed Drs. Wade H. Frost and James P. Leake to assist us in our efforts. When the epidemic began to assume serious proportions and physicians commenced to report suspicious cases to the Department of Health for diagnosis, Dr. Nelson G. Russell and Dr. Edward A. Sharp, consultants on the staff of the Ernest Wende Hospital, were asked to act as expert diagnosticians. These men saw altogether 170 cases. Many were visited more than once. A perusal of the clinical records and laboratory reports compiled by these workers, representing such an enormous amount of gratuitous work, would convince even the most skeptical that there are occasions when a municipality "gets something for nothing.'' Many of the cases were examined with the attending physicians present, which meant that the diagnosticians frequently suited the convenience of others. Night and Sunday calls were numerous and some of the distances covered, long. Such devotion to a profession is nothing if not inspirational. After the smoke of battle had cleared away and the epidemic virtually at an end, the Department of Health was confronted with still another problem, viz.: The care of indigent paralytica left behind by the infantile paralysis scourge. This was brought to our attention sharply when we attempted to discharge "cured" some of these patients in the Ernest Wende Hospital, an institution for acute communicable diseases, conducted by this department, where a number of cases were treated. The situation was met by employing a visiting nurse who, upon request of the physician in charge, cared for cases in the home without cost, administering treatment under the direction of a physician, instructing the members of each family regarding the care of patients, advising mothers generally, and in many instances escorting patients for treatment and advice to the Good Samaritan Free Dispensary, in the Medical Department Building of the University of Buffalo. This work is published for two reasons: First, in the hope that the data contained herein may be of scientific value to future investigators. Secondly, that the method by which the Buffalo,Foreword 5 New York, epidemic was bandied might be of some use to those municipalities throughout the world confronted with a similar situation. Acute anterior poliomyelitis, or infantile paralysis, may well engage the attention of the foremost medical and sanitary minds of the earth. Most examples of acute communicable disease end either in complete recovery or death within a comparatively sho'rt period of time. If a case terminates fatally, the shock is soon over and parents are resigned. What can be more dreadful, tben. than this malady which assails the cradle to find a victim and later, repentant, delivers to the yearning mother a cripple? August 25, 1913. Francis E. Fronczak, M. D., Commissioner of Health, Buffalo, N. Y.INTRODUCTION Poliomyelitis, or infantile paralysis, has becolne, in the last few years, a pandemical disease; or, expressed in other words, a disease which prevails in many and widely different parts of the world. Hitherto it has been a disease of endemic rather than epidemic character and in most countries it has not become so' firmly established as to be classed among the common diseases of the people. Just what the recent pandemical spread means is not now apparent. Whether the disease will remain one of the common diseases of many countries or whether it will tend gradually to die out and disappear generally, except in regions where it has long been established, cannot be predicted. If we reason merely by analogy we may conclude that poliomyelitis will remain impressed upon the United States for many years. This has been the history of a certain number of introduced epidemic diseases, among which may be mentioned influenza and epidemic meningitis. These two diseases, which first appeared as epidemic invasions, have prevailed for many years as sporadic diseases of occasional occurrence, but break out now and again into epidemics of greater or less severity. There is no doubt that poliomyelitis has gradually, continuously and insidiously penetrated from the Atlantic seaboard throughout the territory of the United States and even beyond its borders. Several years have been required to accomplish this extension, but during this period the disease has not entirely disappeared from the locations in which it made its first appearance. Each summer and autumn, and to a less extent in the winter and spring, since 1907, poliomyelitis has appeared sporadically or in small epidemic foci in different places on the Atlantic coast. We are still inaccurately informed of the precise degree of prevalence of poliomyelitis and this arises in part from the circumstance that the disease is still sometimes mistaken for other8 Introduction diseases. The chief severe disease with which it has been and still is, although to a less extent, confused is epidemic meningitis; and this confusion relates especially to the so-called meningeal cases of poliomyelitis and to the early stages of what come to be examples of frank paralytic poliomyelitis at a period at which the symptoms due to meningeal irritation are striking and those due to loss of power in the muscles are less obvious. On the other hand, the mild and very slight examples of poliomyelitis have been and still are mistaken for some of the ordinary affections of childhood. To a certain extent poliomyelitis appears as an indefinite and even evanescent febrile affection or as a simple disturbance of the gastro-intestinal or respiratory tract. It is therefore a very easy matter to overlook these so-called abortive cases of poliomyelitis, and yet their detection is of high importance in respect to the limitation by prophylactic measures of the spread of the disease. In view of the fact that there exists at present no specific form of treatment of poliomyelitis it becomes of the highest importance to ascertain the mode of infection in order that effective preventive measures may be employed. The evidences from human pathology point to two chief sources of infection with the specific cause or virus of the disease. These sources are (a) the upper respiratory tract and (&) the gastrointestinal mucous membrane. An experimental basis has been secured, especially for the first-mentioned portal of entrance of the virus. It has been established by experiment that in the course of- the infection the virus both enters and leaves the nasopharyngeal mucous membrane and also that it is contained within the saliva which, being swallowed, permits its establishment upon mucous membrane o'f the stomach and intestine. Hence it follows that these membranes are to be regarded as the portal of entrance of the virus of the disease into the nervous system and, in addition, the means of its escape into external nature and into man's surroundings. Observations of human epidemics have rendered it probable that the transportation of the virus is accomplished not only by the ill but also by other carriers of the infectious agent. AmongIntroduction 9 the second carriers are included (a) healthy human beings and inanimate objects and (&) insects. The virus of the disease resists drying and many injurious physical and chemical agencies. It is therefore capable of being carried upon the bodies of persons and upon inanimate objects and in a state permitting inplanta-tion upon healthy persons who may be made to develop the disease. Evidence has been secured that such passive carriage sometimes occurs with the parents of children ill of poliomyelitis, and the possibility of the persistence of the virus has been proved for dust of rooms in which patients have been housed, upon objects, etc. It has been demonstrated experimentally that an insect, such as the house fly, is capable of carrying the living virus for a time, not only upon its body but within it, and it has been shown further by experiment that the biting stable fly can be made to extract the virus from the blood of monkeys and reinoculate it into other monkeys which may develop the disease, and that the bed bug can be made also to withdraw the virus from monkeys, retaining it in a living state for several days. But no' evidence has been adduced as yet that shows conclusively that insects play a large and active part in the spread of the human infection, although this possibility is one that should be definitely held in mind. The chief number of cases of poliomyelitis arises during the late summer and early autumn months in the northern hemisphere and the corresponding period in the southern hemisphere. This is the period also during which insect life flourishes most abundantly. The coincidence has been suggestive of a relationship between insects and the disease and this hypothetical relationship is rather strengthened than otherwise by the experimental data related. On the other hand, we must bear in mind that the age incident of the disease is not a uniform one but that young are much more subject to infection than are older persons. Indeed, all but a small percentage of the cases occur during the first five years of life and the percentage arising is higher during the first three years than during the last two of that age period. It is common for suckling children to develop the infection. Still, adults are not wholly exempt and cases of infection arise even in the seventh decade of life, but rarely. Any adequate10 Introduction explanation of the epidemiology of the disease must take into account not only seasonable prevalence but also the age incident. Moreover, the disease is not strictly limited to the summer and early autumij seasons but prevails to some extent in the winter and spring months and in its territorial distribution has been followed into northern latitudes in which insect life even in summer is not especially rich or varied. If we take into account that poliomyelitis is chiefly a disease of childhood and also that the naso-pharyngeal and intestinal tracts commonly harbor the virus we may conclude that the well-known vulnerability of their mucous surfaces in childhood, which subjects them to so many other affections, exposes them also to this infection. In the absence of convincing evidence to the contrary, it would seem wise to direct attention to the spread of the disease through these sources and to adapt protective measures to their control which will incidentally include the elimination of fly infestation as completely as possible. Instances are known in which a suitable and strict system of isolation having been carried out the further spread of the disease has been brought under prompt control. "What makes the carrying out of protective measures difficult are the mistaken cases that are viewed erroneously as examples of meningitis and the milder miscellaneous diseases of childhood. Once attention is emphatically directed to the fluctuation in type and the high variation in symptoms of poliomyelitis the medical profession generally will become more expert in the detection of cases showing less striking symptoms and thus will extend the scope of preventive measures. A good rule to keep in mind is that wherever cases of frank epidemic poliomyelitis arise, other cases, perhaps even more numerous than the frank ones, of the slighter meningeal or abortive forms of the disease tend also to prevail, and with every epidemie of poliomyelitis there is likely to' be a coincident rise in the apparently ordinary affections of childhood. Now it is precisely this rise that should awaken suspicion and lead to a careful examination into the question whether some, many,Introduction 11 or even all of them may not be examples of mild poliomyelitis. If so, the same stringent methods of isolation, etc., should be carried out with them as with the frank cases because, while the slightly affected themselves suffer perhaps little from the disease, they are capable of communicating a severe or even fatal infection to others. New York City. Simon Flexner, M. D.Epidemiology—Frost and Leake ia Epidemiology of the Outbreak of Poliomyelitis, In Buffalo, New York, 1912. By Wade H. Frost, Passed Assistant Surgeon, and James P. Leake, Assistant Surgeon, U. S. Public Health Service. The epidemiologic study of the outbreak of poliomyelitis, in Buffalo, upon which this report is based, was undertaken by the writers by direction of the Surgeon General, U. S. Public Health Service, upon the request of the health authorities of the State of New York and the City of Buffalo. It was begun August 12, 1912, and continued, with an intermission of about ten days during the latter half of September, until November 7th, by which time it was evident that the epidemic had ceased. In order to obtain epidemiologic records a visit was paid, with the consent of the attending physician, to every reported case of poliomyelitis that was accessible, and a systematic inquiry made to ascertain such facts as appeared to have a bearing upon the origin of the infection. During the first weeks of the investigation, Dr. Jesse N. Roe, of the Ernest Wende Hospital, assisted in the collection of case-records, for a considerable number of which we are indebted to him. Assistance was also rendered in this direction by Dr. E. A. Sharp in the course of his clinical study of the epidemic. To the Commissioner of Health and his assistants, especially ten Dr. F. C. Gram, Chief of the Division of Infectious Diseases and Vital Statistics, for the use of all the necessary records of the Health Department, and assistance in arranging many details, we are indebted for their co-operation, which alone rendered the work possible.14 Epidemiology—Frost and Leake Classification of Gases. In compiling the records obtained it has been our aim to exclude all cases in which the diagnosis of poliomyelitis was not satisfactorily established. A large proportion of the cases reported after the study was begun were, during the acute stage of illness, examined by Drs. Sharp and Russell, diagnosticians for the Department of Health, and in the classification of all such cases their diagnosis has been followed. In a certain number of cases not seen by the diagnosticians of the department, and visited several weeks after the acute stage, it was impossible to make a complete examination or to obtain a clinical history sufficiently clear to fully justify a diagnosis of poliomyelitis. Such cases are included in the following tabulation as "suspicious" and are omitted from further consideration in this report. In regard to the cases classed as "abortive," it is believed that in all of these the diagnosis of poliomyelitis is fully justified, notwithstanding that they recovered without having exhibited definite paralysis. Following is a summary of the cases reported: Cases reported to the Department of Health as poliomyelitis or suspected poliomyelitis, from January to November, 1912. . 335 Diagnosed "not poliomyelitis".......... 26 Diagnosis doubtful..................... 12 38 Diagnosis confirmed—poliomyelitis....... 297 Cases classified as £' abortive,'' terminating in recovery without definite paralysis.. . 16 Cases of poliomyelitis resulting in paralysis 281 The above is a statement only of the reported cases of poliomyelitis. It may be safely assumed that the number would be very considerably increased by the addition of unreported and unrecognized cases, especially of the milder types.Epidemiology—Frost and Leake 16 Course of the Epidemic. In Buffalo', as in other large cities, poliomyelitis is not a new infection. Authentic records may be obtained of sporadic cases dating back twenty years and more. The first recorded epidemic in the city occurred, however, in the summer and fall of 1910, when some sixty cases were discovered. The next year, 1911, there were but nine cases reported. In the following summary are given the dates of onset of the cases reported in 1912: TABLE No. 1. Dates of onset of cases of poliomyelitis reported in Buffalo, 1912. January..............................................1 February ............................................0 March ................................................0 April ..................................................1 May ....................................................1 June....................................................9 July ....................................................68 August .......................118 September ..........................................79 October..............................................16 November..........................................1 Total......................*294 To follow the course of the epidemic in more detail, the following table and accompanying chart (No. 1) show the dates of onset of cases in ten-day periods. TABLE No. 2. Cases with onset prior to June 1st............................................3 Cases with onset July 1st to 10th, inclusive..............................1 Cases with onset June 11th to' 20th, inclusive............................2 ♦Three cases, in which the date of onset was not ascertained, are omitted.16 Epidemiology—Frost and Leake Cases with onset June 21st to 30th, inclusive............................6 Cases with onset July 1st to 10th, inclusive..............................11 Cases with onset July 11th to 20th, inclusive............................20 Cases with onset July 21st to 30th, inclusive............................34 Cases with onset July 31st to August 9th, inclusive................36 Cases with onset August 10th to 19th, inclusive......................52 Cases with onset August 20th to 29th, inclusive........................27 Cases with onset August 30th to September 8th, inclusive. . 27 Cases with onset September 9th to 18th, inclusive..................35 Cases with onset September 19th to 28th, inclusive................17 Cases with onset September 29th to October 8th, inclusive. . 11 Cases with onset October 9th to' 18th, inclusive......................4 Cases with onset October 19th to 28th, inclusive......................3 Cases with onset October 29th to November 7th, inclusive... 1 Cases with onset November 8th to 17th, inclusive................0 *290 From the foregoing it is evident that the epidemic was of gradual rather than explosive development, showing a progressive, almost uniform increase from the first of June to the middle of August; then a gradual decline, interrupted by a secondary rise in the middle of September. Curves showing the mean temperature and total precipitation for each ten-day period have been added to Chart No. 2, to indicate the relation between weather conditions and the course of the epidemic. Charts Nos 3 and 4 have been added to give a comparison between the weather conditions during the summer of 1912, and the normal temperature and rainfall for those months in Buffalo'. From the latter charts it is seen that the summer of 1912 was generally cooler than usual. August was notably a cool month, while the mean temperature for September was consider- ♦Seven cases, in which the dates of onset could not he ascertained with sufficient accuracy, have been omitted from this summary.Cases January February March j c < May ui 2 d —> y i> —3 August ui m £ i-c. u (/i October November c£ m r li kj Q 1 20 1 l 0 1 00 00 80 70 SO 50 40 30 2 0 \ i i i \ i 1 0 i 1 t Chart No. 1. Onset of Cases, by Months; 294 Cases (See Table No. 1).--Ml* h TCMPCRAT wOC I l^SHTl i"'I........Hi! = lNO.CS Or «.'»FA1l C - I Chart No. 2. Incidence of Poliomyelitis in Buffalo, by Ten-day Periods, from May to November.•wbm = Normal for Buffalo Chart No. .3. Mean Monthly Temperatures. Buffalo, N. Y.Degrecs F. a < > < E JUNE > j => August CC ■J CD Z u UJ oO October u ao r u > o z 70 G8 /' ^ // \ 66 r # I / 1 I \ > \ \ \ \ \ \ \ 64 / i / i \ \ \ i 62 / i / i / i / # / i \ » \ » \ » \ \ \ t 60 / / / ' / / / / f / \ X \ \ \ X \ X / / / \ » \ 56 X « 1 \ \ X 54 7 \ \ \ X \ X 52 \ \ —= Normal for Buffalo ------- 1912 Chart No. 4. Monthly Precipitation, in inches, at Buffalo. N. Y.No. 1. Map of Buffalo, Showing Wards.No. 2. Map of Buffalo, Showing Distribution of Poliomyelitis.Epidemiology—Frost and Leake 17 ably above normal. The more detailed chart (No. 2) shows a rather uniform mean temperature throughout the month of August, with a slight rise in the first week of September. The increase of cases occurring towards the middle of September, during and shortly after the period of higher temperature suggests that the weather conditions may have been to some extent responsible for this increase, although, on the other hand, this may be a mere coincidence. The rapid decline of the epidemic with the advent of cooler weather, in late September and October, is striking, but cannot be considered as necessarily due to the lower temperature. In other communities epidemics have been known to decline with almost equal abruptness before the onset of cool weather, and again, in still other communities to continue through months of equally cool weather. As regards the relation between rainfall and the course of the epidemic, it is of interest to note that the month of greatest prevalence, August, was a month of unusually heavy rainfall, fairly uniformly distributed. There is, then, no evidence that the excessive prevalence of dust was an important factor in the causation of this epidemic of poliomyelitis. Geographic Distribution. As shown by the accompanying map, cases occurred in all parts of the city. The distribution of cases in various sections is better shown by a study of the number of cases occurring in each of the wards. The following table, compiled to show the distribution of cases by wards shows also, for each ward, the incidence in proportion to the total population and the density of population.* ♦The figures, as to ward-population, area and density of population, are from a Ward-map of the City of Buffalo, the Matthews-Northrup Co., Buffalo, 1911. The population given is that of the Census of 1910.18 Epidemiology—Frost and Leake TABLE No. 3. Distribution of cases of poliomyelitis in the City of Buffalo by wards. Total Population population Per Acre Cases of Poliomyelitis Ward Number of Cases Cases per 10,000 of Population 1 17,947 10.8 10 5.6 2 9,127 17.2 9 9.8 3 16,505 37.5 18 10.9 4 22,639 4.9 12 5.3 5 12,644 54.9 6 4.7 6 11,846 65.8 17 14.4 7 14,462 62.? 10 6.9 8 32,474 63.7 9 2.8 9 20,157 11.7 11 5.4 10 14,711 61.3 9 6.1 11 22,872 65.3 10 3.9 12 24.542 13.8 24 9.8 13 9,925 55.1 8 8.0 14 11,907 51.8 8 6.7 15 19,385 40.4 9 4.6 16 21,901 21.9 16 7.3 17 13,636 2.7 10 7.3 18 21,522 7 6 20 9.3 19 17,219 12.6 15 8.7 20 18,870 27.0 14 7.4 21 13,804 23.8 5 3.6 22 12,136 25.3 10 8.2 23 8,985 34.6 5 5.5 24 15,479 46.9 3 1.9 25 19,016 41.3 25 13.1 423,711 293 6-9Epidemiology—Frost and Leake 19 TABLE No. 4. Comparison of five wards, showing largest proportion of cases, and five wards showing smallest proportion of cases, in respect to density of population. Ward No. Cases per 10,000 of Population Total Population Acres Area Population per Acre Five Wards with largest proportion of cases >-' to tO tO CO W OS 14.4 13.1 10.9 9.8 9.8 11,846 19,016 16,505 9,127 24,542 180 460 490 530 1,780 65.8 41.3 37.5 17.2 13.8 Total............. 11.4 81,036 3,440 23.5 Five Wards wilh smallest proportion of cases i—' 1—' to to Oi « h- 00 (fk 1.9 2.8 3.6 3.9 4.6 15,479 32,474 13,804 22,872 19,385 330 510 580 350 480 469 63.7 23.8 65.3 40.4 Total............ 3.5 103,964 2,250 46.2 The incidence of cases in proportion to population varies rather widely in the different wards. Also the relation between density of population and prevalence of poliomyelitis is quite variable. Of the five most densely populated wards only one (ward 6) shows a proportion of cases above the average; while two of the five least densely populated wards (wards 7 and 18) show a slight excess of cases above the average. Grouping together the five wards with the largest proportion of cases, and the five with the smallest proportion, and comparing these groups in respect to density of population, it is found (table No. 4) that the average density of population is nearly20 Epidemiology—Frost and Leake twice as great in the five wards with the smallest proportion of eases. A close study of the location of cases at various periods during the epidemic brings out the interesting fact that in different sections of the city the disease reached its greatest prevalence at different periods. The following table and chart, showing the occurrence of cases by months in four wards very well illustrate this, showing that in certain sections of the city the epidemic had already reached its maximum and declined before other sections were at all affected. TABLE No. 5. Occurrence of cases of poliomyelitis by months in various wards. Prior to July 1st July August September October and November Total Ward 3 . . . 7 8 2 0 1 Ward 25 . . . 0 16 8 1 0 Ward 12 . . . 0 4 12' 8 0 Ward 22 . . . 0 0 3 5 2 Distribution of Cases Among Various Elements of the Population. Some interesting and significant facts are shown by considering the incidence of cases among the various elements of the population classified according to nationality, according to age, sex, and environmental conditions. Of the various nationalities represented in the population of Buffalo, the Italian, Polish and Jewish are the most distinctive; living, for the most part, in colonies of their own, and mingling comparatively little with people of other nationalities. This is especially true of the Italians, who are mostly rather recent immigrants, speaking English but little. The largest Italian settlements are in the lower end of the 25th ward, and in the 3d ward. These settlements are the most congested and unclean sections of the city.Cases Pri 0 r TO July ! July Aug ust September October and November 1 6 1 4 K 1 \ i \ 1 2 / * # * i i g I 0 / i i \ VX \ 7 \ * 8 i / t It N ./ \ * \ 6 # i \ \ \ 4 / 1 / \ v \ 2 / I \ \ \ I tf \ ____ \ ——^ = Cases or poliomyelitis in Ward 3 K » X M H = I 2 Chart No. 5. Showing Incidence of Poliomyelitis, by Months, in Various City Wards.Cases > < i = I e < June Ju LY August cc LI CCl X u (-Cl u CO October cs: u m LI > o 2 3 2 i K 3 0 i \ i i , % 2 8 2 6 > > V t 2 4 » I \ \ \ 2 2 i i \ » 2 0 1 \ \ I 1 1 8 f 1 1 \ I 1 6 A i / V \ I * I t 1 4 / 1 \ / ' \ \ 1 I i t! 1 2 / 1 \ / 1 \ / 1 \ \ 1 0 / / / / \ \ 8 1 / 1 \ ' ^ \..... \ % t 6 1 1 A \\ \ \ » v i 4 / 1 J l // \ , \ i i i i 2 J l / i / / / v W N< i / / X * --= Cases among Italians ---------= » Americans --—--------- " Poles ............................— " Germans Chart No. 6. Incidence of Poliomyelitis, by Months, in Persons of Various Nationalities.Epidemiology—Frost and Leake 21 The Polish and Jewish population live chiefly in the 6th, 7th, 8th, 9th, 10th, 11th and 12th wards, under conditions which appear to be, on the whole, better than in the Italian settlements, but well below the living conditions of the native-born and more completely Americanized population. The other nationalities largely represented, the German, Irish, English, Canadian and Scandinavian, are more widely dispersed and are mingled more intimately with the native-born population. The accompanying table and chart indicate that the epidemic developed first among the Italian population, reaching its maximum among them in July. The curves showing the development of the epidemic among the other nationalities are approximately coincident, reaching their maximum in August, at a time when the prevalence of poliomyelitis among the Italian population had markedly declined. TABLE No. 6. Nationality (of parents) of patients with poliomyelitis. Jan. to May June July Aug. Sept. Oct. Not. Italians........ 1 4 18 5 2 0 0 Polish......... 1 11 7 0 0 Jewish........ 1 1 7 2 0 0 German........ 4 19 8 1 0 German American . . . 1 9 19 20 3 0 American....... 1 12 33 21 4 1 All other....... 1 3 23 34 18 7 0 Totals......... 3 9 67 118 78 17 122 Epidemiology—Frost and Leake It has not been practicable as yet to estimate the incidence of cases among the various nationalities in proportion to the total number of each nationality in the city. Such rough estimates as have been made indicate a prevalence proportionately greater among the Italians than among the other elements of the population. The classification of cases according to age and sex is presented in the following table: TABLE No. 7. Age and sex distribution of paralytic and fatal cases. Total paralytic and fatal cases Fatal cases Age groups No. cases in each group Percentage in each age group % Number Percentage of mortality % Male Female Total Under 1 year . 15 8 23 8.4 3 13.0 1 to 5 years . . 122 77 199 73.0 21 106 6 to 10 years . 15 23 38 13.9 6 15.8 11 to 15 years . 3 2 5 1.8 2 40.0 16 to 20 years . 4 2 6 2.2 2 33.3 Over 20 years . 1 1 2 0.7 1 50.0 Total .... 180 113 273 100.0 35 Children, age and sex not specifically ascertained. 8 4 281 39 13.8 The 16 cases classed as "abortive"—recovering without definite paralysis—are omitted from this table.Epidemiology—Frost and Leake 23 The age incidence shown above is quite similar to' that commonly found in epidemics of this disease. A better idea of the enormously greater incidence in children may be obtained by comparing the number of cases among them with the estimated number of children in the total population. According to the most recent statistics that have been available,* children under ten years of age constituted 20.2 per cent, of the total population of New York State in 1900. Estimating liberally that children under ten years of age may have constituted 25 per cent, of the population of Buffalo, the following calculations give some idea of the relative incidence of poliomyelitis among persons under ten years of age, and those over that age. Population of Buffalo Census of 1910 Cases of Poliomyelitis (of Specified Age) Cases per 100,000 Population All ages........ 423,715 273 (54.1 Under 10 years (estimated) 105,929 257 242.6 Over 10 years (estimated) . 317,786 16 5.3 According to this estimate poliomyelitis was proportionately about forty-six times more prevalent in children under ten years of age than in older persons. Environmental Conditions. In studying the epidemiology of any disease it is important to take account of the immediate environment of each patient; the general sanitary conditions of the premises occupied. Under this term are considered living-space, ventilation, light, sewage disposal, the presence or probable presence of vermin, and general cleanliness. The last-named is an important consideration, because, generally speaking, the less the attention paid to careful habits of cleanliness in person and surroundings, the greater is the opportunity for the interchange of secretions •Discussion of Age Statistics, Bulletin No. 13, Bureau of Census, Department of Commerce and Labor, Washington, 1904.24 Epidemiology—Frost and Leake and excretions from person to person. Diseases whose incidence depends largely upon conditions arising from overcrowding and improper feeding; diseases transmitted by insects, such as lice, bedbugs and house-flies, whose prevalence in the house is permitted only by the careless and the uncleanly, and diseases transmitted by direct contact from person to person, are generally more prevalent among those who live under what may be called bad sanitary conditions. The following table gives the sanitary conditions noted upon the premises where cases of poliomyelitis occurred or were cared for: TABLE No. 8. General sanitary conditions on premises where cases of polio-• myelitis occurred or were cared for. Excellent in 14 cases 5.4% Good in 87 cases 33.6% Fair in 67 cases 25.9% Poor in 91 cases 35.1% 259 cases 100 % Not noted in 22 cases 281 cases There is, perhaps, a somewhat excessive prevalence among persons living under poor sanitary conditions, since probably less than 35 per cent, of the total population of the city live under conditions which may be so classed. On the whole, however, the distribution among the various social classes, so far as it is shown by the above summary, is sufficiently unifoTm to indicate that the conditions commonly associated with ill-kept and unclean premises are not a predominant factor in causing poliomyelitis. It has frequently been suggested that domestic animals may play an important part in the spread of poliomyelitis. This sug-Epidemiology—Frost and Leake 25 gestion is based chiefly upon the frequent observation, during epidemics of poliomyelitis, of paralytic affections of various animals—dogs, cats, horses, cattle, swine, rabbits and fowls. So far no evidence has been adduced to show that these paralytic affections are etiologically related to human poliomyelitis, and considering that various paralytic affections of animals are rather common, it may well be that the frequency with which such instances have been observed during human epidemics of poliomyelitis is attributable largely to the increased interest which they excite at such times. The only instances of any association with sick animals were the following: Case No. 12—A dog next door was sick a short while prior, paralyzed on one side. Cases No. 13 and 13a—A dog on the premises died in convulsions a month later. In six cases it was stated that cats kept on the premises or on neighbors' premises had recently been sick or died without evidence of paralysis. In three cases considerable numbers of chickens on the premises or near-by had recently died. One case occurred near a veterinary hospital. The instances above cited, in view of their small number, the rather remote association between the sick animals and the patients, and the indefinite nature of the illness of the animals, can hardly be considered as significant. It is, of course, possible that domestic animals, themselves showing no indication of any paralytic disease, may spread the infection of poliomyelitis in man, acting either as passive carriers of the virus, or as the usual hosts of ecto-parasites which may transmit the infective agent to man. In the investigations of the Massachusetts State Board of Health attention has been called to the constantly greater prevalence of poliomyelitis in toiwns where domestic animals are relatively numerous in proportion to the population.26 Epidemiology—Frost and Leake In the investigation of each case in Buffalo inquiry was made as to the number and kind of animals kept on the premises. Domestic animals of some kind were found on the premises in 130 of the cases investigated. These animals were: Cats in....... ..... 62 cases Dogs in....... ..... 50 cases Chickens in....... ...... 40 cases Birds ...... 15 cases Horses in....... ...... 8 cases Ducks in....... ..... 3 cases Rabbits in....... ..... 1 case In practically all cases, even where no animals were kept upon the immediate premises of the patient, they were to be found on neighboring premises. It was quite exceptional, for example, to find a house more than one block distant from the nearest stable. "While there was, therefore, more or less opportunity for every patient to have been to some extent associated with various domestic animals, there is no evidence that the disease was especially prevalent among those most intimately associated with them. Food and Drink. In looking for the source of a sudden epidemic, one naturally turns to the great common-carriers of certain infections—water milk and other raw foods. A consideration which is significant, though not of itself conclusive, is that this epidemic did not exhibit the explosive character which would be expected in an outbreak due to sudden infection of a water or milk supply. Also, a considerable number of the patients were breast-fed infants who drank little or no water; many more of them were young children still on a milk diet and drinking comparatively little water; and finally, the outbreak was by no means limited to Buffalo. The -disease prevailed almost coincidently with equal severity in other towns of Western New York, where the water supply is from altogether different sources.Epidemiology—Frost and Leake 27 As regards the milk supply, suspicion is directed towards that because of the preponderating incidence of the disease among children at the age when milk forms their chief diet. The investigation showed that 225 patients used more or less of raw milk from the following sources: From licensed dairies..................209 cases From local groceries................... 11 cases From private sources (own or neighbors' cows) ............................. 5 cases 225 cases Forty patients used no raw cow's milk at all, viz.: Used no milk at all........................................4 cases Used only boiled, condensed or evaporated milk ..............................................................24 cases Exclusively breast-fed....................................12 cases 40 cases In the remaining thirty-two cases satisfactory information as to the use and sources of milk supply was not obtainable. The 209 patients supplied by city dairies obtained their supply from 120 different dairies, among which the cases were distributed as follows: Dairies supplying 1 patient each, 85 dairies Dairies supplying 2 patients each, 19 dairies Dairies supplying 3 patients each, 6 dairies Dairies supplying 4 patients each, 4 dairies Dairies supplying 5 patients each, 2 dairies Dairies supplying 6 patients each, 1 dairy Dairies supplying 7 patients each, 1 dairy Dairies supplying 15 patients each, 1 dairy Dairies supplying 23 patients each, 1 dairy28 Epidemiology—Frost and Leake The dairies having the largest number of cans among their customers are generally large dairies. A careful comparison of the dairies with more than two cases among their customers taking into consideration the amounts of milk so'ld by each, shows that there was no significantly excessive incidence of poliomyelitis among the patrons of any one dairy. The sources of milk supply of the patients were so various as to eliminate all probability of milk having been an important factor in the spread of the epidemic, it being extremely improbable that so many different sources should have been infected. As, to foodstuffs other than milk, those which fall most under suspicion are fruits and vegetables which are eaten raw. It is virtually impossible to trace back to their ultimate sources the fruits and vegetables which are consumed in a large city. The ultimate sources of supply must, however, be very numerous for a city of the size of Buffalo. It is highly improbable that fruits and vegetables from any single source should have been distributed widely enough to cause the outbreak, and equally improbable that a large number of the sources of supply should have been infected at the same time. There is, of course, the possibility that fruit and vegetables, becoming infected in passing through the hands o'f local dealers, may have contributed to the spread of the infection. This, however, could not account for the whole epidemic, since a considerable number of the patients were infants who had eaten no raw fruits or vegetables. Also', notwithstanding that inquiry was always made as to th$ local dealer supplying green groceries and fruits, no evidence was obtained showing an excessive number of cases among the patrons of any dealer. Contact with Infected Persons. In studying the evidence of contagiousness, attention must be given to two points: First, the number and proportion of patients giving a history of contact with previous cases; and second, the proportion of cases developing among well persons known to have been in intimate contact with patients in the acute stage of infection.Epidemiology—Frost and Leake 29 Histories of contact with previous acute cases of poliomye- litis were obtained as follows: 1. Direct contact: (a) With previous authentic paralyzed case in in acute or convalescent stage................12 cases (&) With previous authentic abortive case in acute stage................................. 2 cases (c) With previous authentic chronic case (of more than six months standing).............. 5 eases (d) With previous suspected case of poliomyelitis .................................... 3 cases Total...................................22 cases 2. Indirect contact: (a) With previous authentic paralyzed case. .. .12 cases (b) With previous suspected case............. 6 cases Total....................................18 cases In addition, indirect contact, generally very casual, with a previous case was said to have been probable but not definitely recalled in nine cases. Altogether only forty-nine (18%) out of 273 investigated paralytic cases gave any history whatsoever of contact, however slight, direct or indirect, with any previous case which might reasonably be considered a case of poliomyelitis. Only fourteen instances of direct contact and twelve instances of indirect contact with previous definite cases may be considered sufficiently authentic to have a definite significance. In the great majority of the cases the family bad absolutely no knowledge of any possible contact between the patient and any previous case. It may be assumed that in a certain number of cases there had been some such contact, either unknown to the patients' families or denied by them, but it is believed that these instances would be. in the aggregate, comparatively few.30 Epidemiology—Frost and Leake The question may now be considered from the opposite point of view, namely, the occurrence of poliomyelitis among persons known to have been in intimate contact with acute cases. Of the 273 paralytic cases investigated, three occurred in institutions. One of these patients was a nurse in a general hospital; the second a patient in the children's ward of another general hospital, and the third an inmate of a large school for boys. It is evident that each of these patients must have been in contact with a considerable number of people during the onset of their attacks, yet there was no other case in any of these institutions. The remaining 270 cases occurred in 267 families, comprising a total of 1,513 people, of whom 762 were children under sixteen years of age. Deducting one person from each family as the "primary" case, there remained, exposed to infection by association with these, 1,246 persons (1,513—267). Among these, cases of poliomyelitis, abortive poliomyelitis and suspected poliomyelitis, occurred as shown in the following table: TABLE No. 9. Incidence of poliomyelitis, abortive poliomyelitis and suspected poliomyelitis in 267 families. Sick 1 Primary | CJ cti Sass ogg Total Sick Secondary 3 9 c Si 2 s a'o§ Poliomyelitis Abortive Poliomyelitis Suspected Poliomyelitis Under 16 yrs. of age 761 260 502 3=0.6$ 3=0.6$ 22=4.4 % Over 16 yrs. of age... 751 7 744 0 0 1=0.23% Considering the small percentage of these intimately exposed persons who developed the disease, there is, in these figures, indubitable evidence that poliomyelitis is not highly contagious in the ordinary sense of the word.. If contagious at all, it must have been only slightly so, the infective agent being either rarely transmitted from the sick to the well, or else rarely finding among the latter susceptible individuals.Epidemiology—Frost and Leake 31 In the majority of cases it was found that a variable number of persons outside the immediate family of the patients had been exposed by visiting their homes before isolation had been ordered, and in not a few instances it was found that the patients themselves had been carried around in railway coaches and street cars, and sometimes taken to public gatherings during the acute stage of their illness. On the whole, notwithstanding the conscientious efforts made to isolate all cases, there was abundant opportunity for the infection to have been widely disseminated, by direct and indirect contact, even from the recognized and reported cases. Of the 263 houses in which these cases occurred, more than half, 142,were occupied by two or more families;in some instances by twenty or more families. Altogether there were, in these houses, 350 additional families other than the families of the patients first attacked in each house. Among these 350 families, residing in such immediate proximity to cases of poliomyelitis, there occurred, subsequently, four cases of poliomyelitis in three families. In the remaining 347 families no known cases developed, thus again indicating ho'w rarely was poliomyelitis transmitted to those in the immedite vicinity of acute cases. Inquiry was made to ascertain what public places each patient had visited shortly prior to illness. The tabulation of all the places which had been visited would lead into much detail. Suffice it to say that many of the patients had not been o"ut of the immediate vicinity of their residences for several weeks prior to their illness, and of those who had been away no considerable proportion had visited any one place or locality. The infection was not, therefore, confined to any particular section or locality, but must have been very widely disseminated throughout the city to have reached so many persons, moving in circles not touching in any discoverable common point. Relation to School Attendance. In considering the possible influence of schools in disseminating the infection, the cases may conveniently be divided into those occurring before and those occurring after the opening of32 Epidemiology—Frost and Leake the schools of the city. In cases investigated before as well as after the opening of the schools, records were obtained relative to the school attendance of each patient and other members of the family. These records embrace 286 cases (paralytic and abortive) of which 202 occurred prior to the opening of the schools on September 3d, and eighty-four on or after that date. Of the 202 cases occurring before September 3d, twenty-eight (13.9%) were in children entered in schools. Of the eighty-four cases occurring after the opening of the schools, twenty-five (29.7%) were in children attending schools, either public or sectarian. The 202 cases with onset prior to the opening of the schools occurred in 197 families, of which 110 (55.7%) had one or more members entered in school. The eighty-four cases with onset on or subsequent to September 3d occurred in eighty-three families, of which fifty-nine (71%) had one or more members in attendance at school. The increase after September 3d in the percentage of cases among school children, and of families having members at school, suggests that the schools, after this date, played an appreciable part in the spread of infection. The grouping of cases in the various schools is shown in the following summaries: Number of families in which poliomyelitis occurred attending various (public and parochial) schools, prior to September 3d. Poliomyelitis in 1 family, 42 schools, equals 60 per cent. Poliomyelitis in 2 families, 19 schools equals 27.1 per cent. Poliomyelitis in 3 families, 3 schools, equals 4.3 per cent. Poliomyelitis in 4 families, 2 schools equals 2.9 per cent. Poliomyelitis in 5 families, 3 schools, equals 4.3 per cent. Poliomyelitis in 6 families, 1 school, equals 1.4 per cent. Total, 70 schools, 100 per cent.Epidemiology—Frost and Leake 33 On and after September 3d. Poliomyelitis in 1 family, 35 schools, equals 72.9 per cent. Poliomyelitis in 2 families, 11 schools, equals 22.9 per cent. Poliomyelitis in 3 families, 2 schools, equals 4.2 per cent. Total, 48 schools, 100 per cent. It is seen from the above that after the opening of the schools there was no significant grouping of cases among the patrons of any particular schools. In fact, the cases occurring during this period are rather more uniformly distributed among the various schools than were the cases occurring in the summer mcfnths, when the schools were closed. It would appear, then, that if the schools did play any considerable part in disseminating the infection after their opening, it was not so much from recognized as from unrecognized sources of infection among their patrons. Evidence of Insect-Transmission. In the investigation of this outbreak it was not possible to make a systematic entomological survey of the environment of each patient; and inquiry as to the prevalence of various insects can not be expected to elicit accurate information. In regard to certain insects, such as lice, bedbugs and fleas, whose presence in a house is very commonly and naturally denied, inferences as to' their probable access to poliomyelitis patients must be drawn chiefly from common knowledge of the usual habits and haunts of these insects, and a general knowledge of the environment of each patient. The occurrence of a very considerable proportion of cases among persons living under good sanitary conditions is, of itself, sufficient to practically exclude such insects as lice and bedbugs from consideration as important factors in the spread of this infection. While it does, of course, happen that these insects are occasionally found in well-kept houses, their presence under such conditions is very rare as compared to their prevalence in squalid surroundings. We would expect a disease34 Epidemiology—Frost and Leake transmitted largely by any of these insects to be characteristically and distinctly a disease of the slums; and this is, in fact, the case with typhus fever, which is transmitted by the louse. The common house-flies and lieas are not so' distinctly restricted in tbeir distribution, yet these two are generally much more prevalent in the ill-kept surroundings of the poorer classes. It is probable that both house-flies and fleas may have had access to every case of poliomyelitis in the city. They can not, on the evidence at hand, be excluded from consideration as possible factors of importance in the spread of this infection, although it would be expected, if the disease were transmitted solely or chiefly by either of these hosts, that the cases would have been more distinctly grouped in certain localities where these insects were most prevalent. The insect which falls most under suspicion as a possible ■carrier of poliomyelitis is the common stable-fly (Stomoxys cal-citraijs). Brues and Sheppard 1 were the first to call attention to this fly as a possible agent in the spread of poliomyelitis. According to their observations in Massachusetts, this was the only biting insect constantly found in the immediate vicinity o'f poliomyelitis patients. Since the recent demonstrations that poliomyelitis may be transmitted from monkey to monkey by the bites of these flies, their possible importance in the natural transmission of the disease demands the closest attention. Observations as to the prevalence of stomoxys in Buffalo were made only during the month of October. During this period, in the investigation of over 100 cases in all sections of the city, stomoxys were constantly found upon the premises or in the immediate vicinity of every patient. Only very rarely, however, were these flies found in the interior of patients' houses. As a rule, even in cold and rainy weather, they were found only out of doors, often around doorways and wandows, but very seldom inside. During October the abundance and activity of stomtfxys decreased very markedly; whereas, during the early part of the (lj Brues, Charles T. and Sheppard, Philip A. E., Monthly Bulletin, Mass. State Board of Health, December, 1911.Epidemiology—Frost and Leake 35 month they were very common and active. By the first of November they were few in number and usually very sluggish. The decline of the epidemic very closely coincided with the decrease in prevalence and activity of these insects. In no' instance was a history obtained of the patient or member of the family having been severely bitten by these flies. In the great majority of cases biting flies had not been noticed at all. In view of the observed prevalence of stomoxys in Buffalo, and what is known of their habits, it is entirely probable that every person who developed poliomyelitis had recently been bitten by one of these flies; but equally probable that the remainder of the population were likewise bitten. In this connection it should be noted that among the class of people most exposed to the bites of stomoxys, namely, hostlers, teamsters and attendants at stockyards and slaughter houses, there was not a single recognized case of poliomyelitis. Also, numerous instances were noted where only a single case of poliomyelitis occurred in the locality where stomoxys were extremely abundant and young children numerous. In the present imperfect state of our knowledge as to the conditions necessary for the transmission of experimental poliomyelitis by stomoxys calcitrans, it is premature to attempt conclusions as to' the role which this insect may have played in this outbreak. The facts presented, while not inconsistent with the hypothesis that the disease was transmitted chiefly through this insect, do not appear to offer any specific evidence that such was the case, being equally consistent with the hypothesis that the infection was chiefly disseminated by more or less direct contact from person to person.36 Epidemiology—Frost and Leake SUMMARY. The study of this outbreak has developed nothing new or distinctly unusual in the epidemiology of poliomyelitis. In general characteristics and course this epidemic was similar to those which have been studied in other cities. An infection presumably present in the city for many years, became progressively more prevalent without discoverable specific cause. From a somewhat ill-defined focus chiefly among the Italian population in June and July, the epidemic spread over all sections of the city, attacking, however, only about one in 1,400 of the population, those attacked being almost exclusively children, with a very few young adults. The outbreak can not be ascribed to purely local causes, for the reason that outbreaks of equal severity occurred in other localities in the State at about the same time. Nor can it be ascribed to any specific peculiarity in the weather conditions, for epidemics have occurred in other communities under conditions which appear to have been very different—certainly very different as regards temperature and rainfall. One of the most significant facts brought out is that in certain groups of the population (in the residents of certain wards and in the Italian population as a whole) where the epidemic developed earliest, it died out early, while sitill on the increase in other groups. This indicates that the evolution of the epidemic was, to some extent, independent of such variations in local weather conditions as took place between June and October. It also gives the impression that the infection was widespread, perhaps almost universal, passing successively over different areas of the city, attacking all or most of the susceptible individuals and then dying out in that particular section. It is difficult on any other basis to account for the rarity of cases during August and September among those groups of the population which had suffered most severely in June and July, for undoubtedly these groups must still have been constantly exposed to reinfection from their neighbors, as well as from the convalescent patients in their midst.Epidemiology—Frost and Leake 37 The fact that only a very small proportion of the cases had been in known contact, either direct or indirect, with any previous recognized case of poliomyelitis does not disprove the contagiousness of the disease, its direct transmissibility from person to person. It does, however, prove quite conclusively that if the disease is commonly so transmitted, the clinically recognized cases of poliomyelitis are relatively unimportant sources of infection. Other sources of infection, most probably mild, unrecognized cases and passive human virus carriers, must be more important than the recognized cases. The wide scattering of cases would also appear to indicate quite convincingly that if the disease is commonly transmitted by biting insects, these must ordinarily derive their infection from sources other than human cases of poliomyelitis; and that only a small proportion of the persons bitten by such infected insects develop the disease in clinically recognizable form. In short, whichever route of infection is considered, direct transmission from person to person or transmission through a biting insect, one is almost forced to the conclusion that the infective agent is disseminated chiefly from sources other than the recognized cases. The only demonstrated sources of the virus, other than persons suffering from clinically recognizable poliomyelitis, are those suffering from slight, clinically indefinite illness, and passive human carriers. "While it is quite within the bounds of possibility that domestic animals or insects may be natural sources or reservoirs of infection, there is at present no proof whatsoever that such is the case. Finally, as regards the demonstrated occurrence of passive human virus carriers, analogy with other infectious diseases prepares us to expect that the virus of poliomyelitis, finding lodgment upon the mucous membranes of a healthy person, might develop there without causing a true infection of the individual; in fact, without necessarily reaching the interior of the body. It is, however, difficult to understand how the virus, if introduced into the circulation by a biting insect, could so multiply as to be excreted through the mucous membranes without causing any clinical reaction.Clinical Pathology—Fraser 39 Clinical Pathology of Acute Anterior Poliomyelitis. FRANCIS R. FRASER, M. D. Until recent years the pathology of acute poliomyelitis was limited to the knowledge that in chronic cases atrophic lesions are found in the anterior horns of the gray matter of the spinal cord. In 1871, Roger and Damaschino published an account of the paithological findings in one case in a more acute stage, and since then numerous reports have appeared. Wickman, in 1905, and Harbitch and Scheel, in 1907, reported on investigations during epidemics in Sweden and Norway, and emphasized the interstitial character of the changes in the brain and cord. They referred also to changes in other organs of the body which, in comparison with those in the central nervous system, were considered relatively unimportant. These changes consist of cell proliferation and degeneration throughout the lymphatic system of the body, with enlargement of the lymphatic glands. The tonsils and lymphoid nodules of the spleen are enlarged and similar changes are seen in the Peyer's patches of the intestines. The liver also shows cellular infiltration. A recognition of these changes and of the abnormal condition of the blood and spinal fluid found in clinical investigations has done much, to give a picture of the whole process of the disease from the onset. In the epidemic form of the disease the first localization of the infection thiat is at all constantly suggested by the clinical picture is the meninges—in other wo"rds, the disease at the onset presents often the picture of a general infection with an inflammatory condition of the meninges. The close anatomical relations of the lymphatics of the upper nasal cavities with the lepto-meninges, and the findings of Flexner, Lewis and Clark in tracing the virus from the nasopharynx to the olfactory lobes of the brain in the experimental disease in monkeys points very strongly to that path as the mode of infection in the naturally acquired disease.40 Clinical Pathology—Fraser An examination of the spinal fluid presents a markedly pathological condition. The fluid is usually slightly increased in amount; it is clear and colorless, though a slight opalescence is frequently observable; and there is an increase in the cell content and in the amount of globulin present. The cell content can be easily determined by mixing the fluid with acetic acid in the white cell counting pipette of a hematocytometer, drawing up acetic acid (10-50%) to the "1" mark on the stem and filling the pipette with the spinal fluid. After a thorough shaking, a counting chamber is filled and the cells counted. The globulin content is readily gauged by the butyric acid method of Noguchi. The procedure of lumbar puncture is not a difficult one and, if proper aseptic precautions be taken, causes no inconvenience to the patient. In the case of children, the quantity of fluid withdrawn need not be the subject of special precaution, as quantities as large as 30 to 40 cc. may be taken without inconvenience to the child. The most usual type of fluid found is one containing a moderate cell increase of between ten and fifty cells per cubic millimeter and a well-marked globulin reaction, but the cells may number over 1,000. In the first week after onset ef symptoms, the proportion of cases showing high cell counts is at a maximum, while it is in the second week that the proportion of cases showing increased globulin content is at its maximum. Over 90 per cent, of cases examined during the first week after onset show fluids abnormal either in their cell or globulin content or both, and of 126 cases admitted to the hospital of the Rockefeller Institute for medical research during the years 1911 and 1912, there were only five that never showed any abnormality at the examinations of their spinal fluids. Though in a few cases, at a very early stage, the polymorphonuclear cells have outnumbered the mononuclears in the fluid, the cell increase is almost entirely due to mononuclears. These mononuclears are of various types, and while in the later stages the lymphocytic cells predominate, in the early fluids large mononuclear cells, often with irregular nuclei and sometimes with vacuolated cytoplasm, are in excess. Degenerate cells, showing a large disintegrating nucleus and mere irregular strands of cytoplasm, or often none at all, may be present to the extent of over 20 per cent.. WhereClinical Pathology—Fraser 41 these cells originate is still an open question, but judging from the studies on similar cells in other diseases of the meninges, they are probably mostly derived from the periarterial tissue of the meningeal vessels. An examination of the blood, as reported by Draper, Pea-body and Dochez, shows an increase in the white corpuscles of the blood of a moderate degree, "a leucocytosis," they say, "of 15,000 to 30,000 is distinctly suggestive of the disease in question, especially if the polymorphonuclear cells are increased at the expense of the lymphocytes.'' This leucocytosis was greatest in the first week of the disease and gradually diminished as the signs of acute infection passed off. A routine examination of the urine over a large series of cases showed no constant abnormality^ though a slight degree of albuminuria occurred in several cases. An examination of cases dying in the acute stages shows an cedemattfus condition of the meninges and of the surface of the brain and cord, and an engorgement of the superficial vessels of the brain and cord. On section the gray matter of the cord presents a pinkish gray appearance and is raised appreciably above the cut surface. On histological examination the most marked, feature is the cellular infiltration about the vessels entering the cord, and especially around the large artery of the anterior commissure. This artery may be traced in sections to the anterior horns of the gray matter, and throughout its branches the cellular infiltration is seen and sometimes it is so great as to actually press on the vessel and diminish its lumen. The anterior horn cells are found in various stages of degeneration, hsemoT-rhages, microscopic or often visible to the naked eye, are present and destroy the cells in that part of the gray matter, while in other parts the cells present an cedematous swollen appearance. These changes of congestion, haemorrhage and oedema are not limited to the cord but are frequent in the medulla and are found in the cerebrum and cerebellum, nor are they limited to the anterior horns of the gray matter, but are found, though less frequently, in other parts of the spinal cord. The posterior root ganglia are peculiarly constant as regards the presence of these pathological changes. Clinically it is found that while paralysis42 Clinical Pathology—Fraser may be very extensive at the onset, it dears up more or less rapidly in the case of the majority of the muscles affected as the acute stage passes off, and leaves certain muscles or groups affected that may recover gradually over a long period or, on the other hand, never sho'w any return to power. Pathologically this admits of explanation in that a more or less rapid clearing up of the oedema and haemorrhage allows of an early recovery in the function of the nerve cells and early return of po'wer in the muscles, while some cells are irretrievably damaged and cannot recover and undergo a gradual process of disintegration and absorption by the invasion of phagocytic cells—a process that is well seen in the histological study of the spinal cord. Clinically also, various types of the disease are recognized according to the anatomical distribution of the paralysis, and pathologically it is recognized that the lesions may be distributed generally throughout the cord and medulla, or may be quite limited as regards the more intense degrees of change to certain parts of the central nervous system. "Well marked lesions, however, are frequently found in the cord for which no' corresponding clinical phenomena were present, and conversely, cases that present well developed paralyses, especially of the bulbar type, frequently show7 comparatively mild changes in the corresponding parts of cord or medulla. Clinically also it is recognized that while some cases spread progressively, others are arrested after comparatively slight involvement has resulted, and it is easily conceivable from the pathological aspect that the changes may be quite slight in distribution and severity, or indeed may be almost limited to the meninges. Cases are described as meningitic in whidh the paralysis is very slight or absent, while the meningitic symptoms are severe, and the study of every fresh epidemic increases the evidence of the occurrence of abortive cases. In the other organs and tissues of the body very constant changes are described. They are, however, of such moderate severity as compared with those found in the central nervous system, that the clinical conception of the disease as one affecting the central nervous system is but natural. In the lymphatic tissue throughout the body there is marked evidence of reaction to the virus, and the lymphatic glands are generally enlarged in the cervical,Clinical Pathology—Fraser 43 axillary and inguinal regions. The spleen is frequently enlarged and on section the Malpighian corpuscles are more noticeable and have a pale, translucent appearance. The tonsils also share in this general enlargement, which perhaps is most strikingly seen in the Peyer's patches in the intestine and in the mesenteric lymph glands. On histological examination the lymph sinuses show a proliferation of the endothelial cells and much cellular necrosis, and the lymphoid nodules present areas of lymphocytes surrounding a center of large endothelial cells that are swollen and degenerate and frequently observed to be necrotic. Somewhat similar lesions are described in the liver. The clinical picture in the acute stage of the disease suggests a general infection, and in every extensive epidemic prodromal symptoms are described that, though occasionally referred to the respiratory system, are far more frequently digestive in character and include loss of appetite, vomiting, constipation and diarrhoea. Many of the prodromal symptoms can be accounted for by the visceral and lymphatic lesions and by the affection of the meninges, as shown clinically by lumbar puncture. The sudden onset of paralysis may be accounted for by congestion, haemorrhage and oedema, and the rapid recovery of many muscles and muscle groups by the early absorption of the infiltration and exudate. The permanent paralyses may be due to the necrosis-and absorption of the severely damaged anterior horn cells, and for the various clinical types met with in epidemics there are similar variations in the localization and distribution of the pathological lesions.Diagnosis and Treatment—Russell 45 Diagnosis and Treatment of Acute Anterior Poliomyelitis. NELSON G. RUSSELL, M. D. Since the possibility of direct transmission of acute anterior poliomyelitis has been established, the early diagnosis of the disease has assumed a greater importance, but so far there seems to be no pathogonomonic sign or symptom of the malady. Clean-cut cases beginning with intestinal disturbance, with Or without vomiting or diarrhoea, vague pains in various parts of the body and more especially stiff neck and drowsiness, followed by flaccid paralysis, give no trouble in diagnosis. Most of the cases occurring during the Buffalo epidemic of 1912 were not seen for several days by either Dr. Sharp or myself, as the attendant physician did not call for diagnostic aid from the Health Department. There are numerous doubtful cases in an epidemic of this kind which remain on the border line for a number of days, and it was these which gave us the greatest opportunity for study. Some of them exhibited symptoms of meningitis, multiple neuritis, cerebral symptoms with slight or no evidence of paralysis and occasional spastic paralysis. In addition to the doubtful ones there seems to be undoubted abortive cases which may play a very important part in the epidemiology. Without lumbar puncture and examination of the spinal fluid in the latter type, there is no way of making a definite diagnosis. "We had the opportunity in the series of eases under discussion, of examining the spinal fluid in three abortive cases. In these we found the cell count and other findings corresponded very closely to the data elicited from the definite paralytic types. Symptoms generally looked for throughout the epidenmic were, intestinal disturbance of almost any nature without definite cause, associated with vague pains, stiff neck and drowsiness, as a rule followed by irritability and distinct tenderness. These were followed, anywhere from a few hours to ten days, by paralysis of greater or less degree. The extent of this paralysis is shown in the charts and histories given by Dr. Sharp in his repoTt. Where we had the opportunity, the blood and spinal fluid were studied.46 Diagnosis and Treatment—Russell The blood in the majority of the cases showed a moderate hyper-leucocytosis running as high as 30,000 in one case but averaging about 15,000. There was a relative polynuclear increase in practically all of the early cases cited. The spinal fluid was examined in forty-one cases reported with a definite diagnosis; and in seven cases reported "suspected." We procured the fluid in the usual manner with an ordinary good-sized needle, taking as a rule from ten to' fifteen cc. This was examined immediately, the cell count estimated with the usual haemocytometer, diluting the fluid with two per cent, acetic acid to remove the red cells from the field in case of contamination. We also counted some of the fluid clear i.n such cases to estimate the number of white cells probably associated with the cells normally belonging to the spinal fluid. This, however, was necessary in only a few instances. We made smears from the centrifuged fluid for differential count. These were stained with methylene blue after fixing with bichloride of mercury. The fluid was also examined for globulin by the Nogu-chi method; viz.: .1 cc. cerebro-spinal fluid mixed with .5 cc. ten per cent, butyric acid in physiologic salt solution and the "mixture heated. .1 cc. of normal solution of sodium hydrate is added and the whole boiled for a few seconds. A granular or floc-culent precipitate appearing after a few minutes to one or two hours indicates an increase of globulin. Fehling's solution test was used. This is simply the addition of the cerebro-spinal solution to Fehling's solution and boiling in the usual way. The copper is precipitated by normal cerebro-spinal fluid, also by infantile paralysis spinal fluid, but the solution is not affected by "the spinal fluid of purulent meningitis and not as a rule by the "spinal fluid of tubercular meningitis. The cell counts in our cases ranged from eight cells in a case five days old to one hundred and twenty-eight cells in a case before the onset of paralysis. The increase in cell count persisted as late as three weeks in one case examined but we did not follow up our work by repeated examinations so cannot give any reports on the later findings. The average number of cells in forty-one cases was thirty-six. Four cases classed as abortive—that is, with the intestinal disturbance, drowsiness and stiff neck but without any paralysis, gave an average count of twenty-sevenDiagnosis and Ireatment—Russell 47 cells and all gave the globulin reaction. In our series of patients only one failed to reduce Fehling's solution, but this specimen of fluid was not examined on the day it was taken, so this test was not concusive. A globulin reaction was present in all of our cases upon which it was tried, but not in proportion to' the cell increase; in fact, one child examined on the first day with a definite paralysis of both legs showed a cell count of only nine cells and yet a very positive flocculent precipitate with a butyric acid test. The conditions simulating infantile paralysis which we saw or were reported to the Health Department wrere: Four cases of tubercular meningitis, one case of typhoid, one case of multiple neuritis, one case of apical pneumonia, three cases which seemed to be simply toxic conditions with every other indication of intestinal infection. The cell count in the tubercular meningitis cases was very little higher than the infantile paralysis counts. The polynu-elear cells averaged four per cent, higher than the paralysis cases, which ran from no polynuclear to twelve per cent., the twelve per cent, count being in the pre-paralytie stage. The globulin was increased in all of the meningitis cases, Fehling's solution was reduced by one of them and we were able to detect the tubercular bacilli in two of these, but the organisms were discovered only after a long search. Failure to detect them in the ordinary clinical laboratory should not exclude the condition by any means. The pneumonia case showed a perfectly normal spinal fluid, as did the three toxic cases, but the typhoid gave a cell count of nineteen without increased globulin and ninety-two per cent, mononuclear cells. This was rather confusing for a few days until the patient ran a perfectly definite typhoid course with positive Widal reaction and no evidence of any paralysis. This finding rather weakened our faith in the spinal fluid examination as being of absolute value in the diagnosis. We were without proper facilities to attempt serum diagnostic procedures and cannot report as to their value. We feel, however, that the spinal fluid study, when all of the four methods are taken together, is still the mo'st important part of an examination for diagnosis in a doubtful case of acute anterior poliomyelitis.48 Diagnosis and Treatment—Russell Treatment. As the cases under our observation were scattered all over the city, with the exception of a small number in the wards of the Ernest Wende Hospital, we were unable to carry out any definite plan of treatment. The cases in the wards of the hospital arrived anywhere from two or three days to two weeks after onset, so that even here we had no definite outline of treatment from the beginning. The cases were treated at first as we would treat any acute infectious disease; that is, by elimination, catharsis, hot baths, packs, foot baths and attention to diet. We immediately started every case on Urotropin with the hope that it might have some action in the spinal canal. Symptoms such as pain and restlessness were treated with bromides or antipyrine and occasionally we resorted to codeine or morphine. Hot packs or hot baths were kept up as long as temperature or tenderness were present. The paralyzed parts were subjected to some passive motion very early, in fact, as soon as tenderness would permit, with the idea of preventing contractures, which in a few cases began almost immediately. "We felt that in pursuing this course we were able to forestall a good deal of disturbance during convalescence. The orthropedic attendant devised various kinds of apparatus to keep the patients as comfortable as possible and at the same time keep the paralyzed parts in nearly normal position. All of the massage and after-treatment was under the direction of an orthopedist and did not fall in the province of the medical attendant. The Health Department provided a nui*se to follow up the cases in their homes, also under supervision of the consulting orthopedic attendant. Thus all of the cases not properly cared for otherwise were directed as to treatment and in some instances taken to a free dispensary for other necessary measures. One plan of treatment used, which has not been very generally adopted, was the introduction of adrenalin solution into the spinal canal in cases of progressive paralysis. In two cases where this was administered progress stopped immediately; in three others the apparent results were not so good, but in these the paralysis had already affected respiration. The amountDiagnosis and Treatment—Russell 49 administered was from one to two cc. of the one to one thousand solution. From our observations during this epidemic we feel there is no clear-cut outline of treatment to be adopted. "We obtained our best results with an early cathartic, light diet, hot packs or hot continuous bath and general attention as to hygiene and diet, with the possible administration of Urotropin in every suspected case and the introduction of adrenalin into the spinal canal in progressive cases.Clinical Types and End Results—Sharp 51 Acute Anterior Poliomyelitis. Some Clinical Types and End Results of the Buffalo Epidemic of 1912. By EDWARD AFFLECK SHARP, M. D. The following report of the clinical manifestations and clinical types of acute anterior poliomyelitis is based on the personal study of 170 cases observed in the Buffalo epidemic of 1912, which came under the jurisdiction of the Health Department. In addition, a number were examined in surrounding towns, and twenty-four of the Buffalo cases examined were found not to be poliomyelitis. These two latter groups are not included in the present report. A number of patients were under observation at the Ernest Wende Hospital, and in a large proportion of the other cases opportunity was afforded to study the clinical course of the disease from the onset, or early in the acute stage, before the development of any paralyses. Unfortunately definite data regarding certain symptoms occurring before the cases were examined could not be obtained in some instances, hence statements regarding the frequency of certain symptoms are necessarily incomplete. Of the total number of 170 patients examined, ninety-two were males and seventy-eight females. The average age was about four years; the youngest being three months (two cases) and the oldest twenty years (two cases). Fever was the most constant of the early symptoms and was noted 165 times. The remaining five cases were reported as having had no fever, but as the temperature was not taken with a thermometer it is possible that the apparently normal surface temperature was not an accurate observation. In 114 patients the onset was described as sudden; i. e., a child in good health was taken suddenly ill with fever and other52 Clinical Types and End Results—Sharp constitutional disturbances. In fifty-six cases there was a more gradual onset of the illness, with malaise and indisposition or slight fever for a day or two or longer before other acute symptoms became noticeable. Five had convulsions at the onset. In thirty-seven instances the acute attack was followed by a remission of a day or two or longer in which the symptoms apparently subsided and the child was allowed to be up and about. Then, without warning, a return of the fever and other symptoms occurred with greater severity. The future course of these cases was usually more severe than in those without the remissions. Vomiting was noted as a temporary symptom at the onset eighty-two times, quite severe and of projectile character in two cases. Where accurate data regarding the bowel condition previous to onset of the other symptoms could be obtained, it was found that sixty-three sufferers were constipated before and at the time the first symptom appeared. In thirty-one cases diarrhoea occurred, either as an early symptom with other gastrointestinal disturbances, or the initial constipation was followed by diarrhoea in a day or two'. Usually this happened after the administration of the first cathartic, the stool becoming greenish and foul-smelling. Headache was undoubtedly a more frequent symptom than was noted in fifty-six instances. The younger children did not complain of pain in the head, but incessant crying would indicate that it was present. Six of the older children complained of vertigo. Some increase in the irritability and restlessness was present in most of the cases, and in ninety-nine, these symptolms were reported as abnormal. Definite drowsiness was noted 117 times, but in only five cases was the opposite condition of excessive alertness observed. In the remaining cases drowsiness was not sufficiently marked to be noticeable by the parents.Clinical Types and End Results—Sharp 53 Twitching or jerking of the muscles, sometimes of a fine fibrillary character and occurring only during sleep, afflicted sixty-five victims. Twenty-four patients exhibited a more marked tremoT or trembling of the extremities. As far as could be observed these fibrillary twitchings were not more noticeable in the parts which later became paralyzed, in most of the cases; although in a few instances this was apparently so. The symptom was considered a general one of toxaemia and irritation, without localizing value in determining which parts would become paralyzed. In a majority of the patients examined during the acute stage some pain or stiffness in the neck or back, of resistance to anterior flexion was observed, but in the tabulation of the data this symptom was recorded in only ninety-seven of the cases, as the histories of some cases not examined during this stage were questionable. Definite retraction of the head was observed forty-seven times. Pains in the extremities were more or less severe in fifty-four instances. In a few this was so severe and the tenderness of the nerve trunks so' marked that the condition resembled a polyneuritis. In none of these could any thickening of the nerve trunks be demonstrated. The Kernig sign was elicited in twenty-six patients and the Brudzinski neck sign in seventeen, but in many these signs were not looked for during the acute stage. The character of the reflexes varied with the stage o'f the illness during which the examinations were made. In the preparalytic stage the usual condition was an exaggeration of the reflexes. With the onset of weakness or paralysis the tendon reflexes were diminished or lost in the parts involved. In some of the meningeal types, without paralysis, the reflexes were exaggerated throughout the course and accompanied by clonus. Paralysis or weakness occurred in most of the cases on the second or third day of illness. In a few persons the weakness or paralysis appeared to be an initial symptom, or at least the previous symptoms were so slight that they were not observed. In54 Clinical Types and End Results—Sharp one case of this series there was an interval of fourteen days between the onset and the development of the paralysis. In eighteen cases no paralysis occurred, or if some weakness appeared for a short time it was unobserved and not present at the time of the examination. These included most of the meningeal cases and the aborted attacks. In fourteen cases there occurred oily temporary weakness lasting from a few days to a week or two. The usual type of paralysis was that involving one or more extremities or parts of the extremities. The lower limbs were most frequently affected; the right eighty-one times and the left eighty; in forty-nine cases both lower extremities were involved. The paralysis was usually more severe in one extremity than in the other and was rarely symmetrical. In the upper limbs the right was involved in thirty-one, the left in twenty-eight and both extremities in fifteen cases. One or more of the cranial nerves were involved in sixteen instances. Usually this was accompanied by some involvement of the extremities. In only five cases was no extremity involvement observed. A cerebral type was apparent in two instances. The onset, with convulsions, was followed by hemiplegia. One of these had exaggerated reflexes on the weakened side but the recovery from the hemiplegia was nearly complete in a month. This case had all the appearances of an ordinary infantile cerebral palsy from encephalitis and would not have been considered as a manifestation of poliomyelitis had it occurred outside the epidemic. It is possible that the virus of poliomyelitis is more frequently a cause of infantile cerebral palsy than is usually accredited. The other cerebral case had nine or ten convulsions at the onset, with hemiplegia following; the reflexes were diminished on the hemiplegic side and there was considerable hypotonia in the lower extremity with less complete recovery. Ataxia was a marked symptom in eight persons. In two of these the ataxia was not associated with paralytic symptoms and they were classified as of the ataxic type. Three of the patients were classified as of the polyneuritic type. Pain in the extremities and tenderness on pressure was aClinical Types and End Results—Sharp 55 marked symptom in fifty-four cases, as stated above, but these symptoms were nearly all associated with paralysis of the spinal type. In the three polyneuritic types the pain and tenderness along the nerve trunks was very severe for several weeks. In fifteen of the cases the clinical picture was that of a more or less severe meningitis with no definite paralysis or only temporary weakness, and these were classified as the meningeal type. Severe meningeal symptoms were exhibited by a number of sufferers who later became paralyzed. While thirteen of the cases were reported as "aborted," only five in this group were considered as simple aborted, i. e., cases which showed only slight meningeal irritation Or other signs of nervous involvement in addition to the constitutional disturbances. The other patients showed some slight paralytic phenomena, as weakness, or other signs of motor disturbance, all of temporary duration. The most severe and fatal form was that corresponding to the Landry paralysis type of the disease, in which, the involvement gradually extended from onie extremity to the other. In some of these the diaphragm and intercostals became paralyzed. Sixteen were of the Landry type of paralysis and twelve of this number died. The remaining four have been left severely damaged. Summarizing the above cases and placing them in groups according to the predominating symptoms or definite types, the following classification may be made, based on the types recognized by "Wickman: Spinal and bulbar types. .. 127 cases Cerebral ....... Ataxic ......... Polyneuritic Meningeal ...... Aborted (simple) Landry type.... 2 cases 2 cases 3 cases 15 cases 5 cases 16 cases Total 170 cases66 Clinical Types and End Results—Sharp While the majority corresponded more or less closely to the above, mixed types or a combination of two or more of these were not uncommon. A complete and final report on the end results of the entire epidemic cannot be given, as about 100 of the cases have passed out of Observation, while others still continue to show improvement. The meningitic and aborted types have recovered without any loss of function. During February and March, 1913, Dr. Edgar Bieber, of the Ernest Wende Hospital House Staff, examined 205 of the cases reported during 1912 and found only fifty-two in which recovery had been so complete that no disturbance of muscular function could be discovered. The usual result, therefore, has been some residue of paralysis or weakness varying in degree from complete loss of function of the extremity involved to a mild degree of weakness of individual muscles. Where it has been possible to examine cases carefully, charts showing the original muscles paralyzed have been made and later other charts executed showing the progress of recovery. The accompanying diagrams illustrate this very clearly. No. 1 shows the extent of paralysis at the height of illness. No. 2 shows the condition ten months later. Some residue of paralysis can usually be found on careful testing and the electrical reactions frequently show degeneration in the parts involved. A considerable number of the 205 patients mentioned above have deformities of the joints, contractures, etc. They are now orthopaedic cases. Proper orthopaedic treatment ought to modify still further the end results of the paralyses. The record here set forth plainly indicates that acute anterior poliomyelitis is not a simple trivial disease and that recovery from the acute stage does not end the care of a case, which may go through life crippled and deformed.abductors, and quadriceps femoris group. Weakness of anterior and posterior leg muscles. Weakness of glutei and hamstrings. No. 1. Showing recovery of most of the functions, except slight weakness of right deltoid and weakness of the flexors of left thigh and the anterior letr muscles. Slight limp and foot drop. No. 2.Post-Infantile Paralysis Cases—Goodale 57 Post-Infantile Paralysis Cases. WALTER S. GOODALE, M. D. Hospital treatment for communicable diseases becomes a fairly popular measure with the masses in direct proportion to the stringency with which isolation is enforced when the only other alternative is chosen, viz.: Home treatment. Infantile paralysis, during the Buffalo epidemic of 1912, proved no exception to this rule. Previously a reportable disease only, Health Commissioner Fronczak declared that it should be isolated like smallpox, scarlet fever and diphtheria; the house placarded and inspected by the department policeman frequently. Accordingly, when the citizens demanded institutional treatment for this disease two wards were set apart in the Ernest Wende Hospital. Here twenty-eight eases were received. Of these four died, all on the day of entrance. The average stay per patient was twenty-five days, which calculation includes the four who died upon admittance. Of the living patients, two spent seventeen days in the institution, while one stayed forty-nine days. The cither patients sojourned with us for various periods between these two extremes. The returns for the entire city during the epidemic show 281 undoubted cases of acute anterior poliomyelitis. It will be seen that practically ten per cent, of all cases reported were admitted to the Ernest Wende Hospital—not a bad showing for a municipally conducted institution when one considers1 that this malady had hitherto received scant attention, either at the hands of the public or the medical profession. All of these patients were under the direct supervision of Drs.Nelson G.Russell and Edward A. Sharp, who elaborated a course of symptomatic treatment, as outlined in another section of this work. It soon became evident that the care necessary during the active stage of the disease was insignificant when compared with the problem presented upon attempting to discharge an inactive, paralyzed case into a home where the ordinary decencies of life58 Post-Infantile Paralysis Cases—Goodale were conspicuous by their absence. When this latter situation arose, the Department of Health determined to. employ a visiting nurse to tend all indigent post-infantile paralysis sufferers. Her work was necessarily confined to the poorer classes, principally for the reason that the ordinances of the city did not provide a position covering these duties. Hence, one nurse only was detached from the Ernest Wende Hospital staff and detailed for this special1 work. The physicians of Buffalo were circularized for the purpose of conveying the information that a nurse was available, as above outlined, upon request of an attending doctor only. The circular also conveyed the information that a consulting orthopedist would be available gratis. Drs. Ward W. Plummer and Prescott LeBreton were appointed to act in this capacity. Altogether fifty-five patients availed themselves of the gratuitous nursing service offered. It soon became apparent that one nurse could not care for properly so many persons scattered over a large area. A plan was then devised whereby patients, in charge of the nurse, could visit the Good Samaritan Free Dispensary, lo'cated in the Medical Department Building of the University of Buffalo, as often, as necessary for the purpose of obtaining advice and treatment. Here Dr. Edward A. Sharp, in addition to the orthopedists mentioned above, treated a number of cases. Occasionally the ambulance attached to the Bureau of Hospitals was used for the purpose of transporting patients to the Dispensary and return. Up to the present writing, the following tabular statement indicates the result of the work outlined above: Total number of patients treated by nurse... 55 Discharged.............................17 Died (epileptic convulsions)............... 1 Moved to parts unknown.................. 2 20 Total number number under observation at present time........................... 35Post-Infantile Paralysis Cases—Goodale 59 Seventeen of the thirty-five are making marked improvement, while fifteen show slight improvement only. Three are out of the city temporarily, hence their condition is unknown. The accompanying table, detailing the reasons why seventeen patients are recorded discharged, is somewhat illuminating: Case No. 1—Cured. Case No. 2—Much improved. Case No. 3—Mother refused treatment. Case No. 4—Family friend treating patient, whom mother deems more competent than nurse. Case No. 5—Attending physician advised that treatment be discontinued. Patient still disabled. Case. No. 6—Mother a practical nurse. Prefers to give treatments personally. Case No. 7—Family physician advised treatment to be discontinued and ordered brace. Case No. 8—Removed to orphan asylum. Case No. 9—Receiving private treatment of some sort. Wears brace purchased at drug store. Case No. 10—Discharged at mother's request. Reason not given. Case No. 11—Discharged at mother's request. Reason not given. Case No. 12—Receiving private treatment of some sort. Case No. 13—Mother thinks treatments are unnecessary. Case No. 14—Child badly damaged. Creeps with difficulty. Slovenly mother, who decided that treatments were useless. Case No. 15—Wears brace purchased in drug store. Mother considers treatments unnecessary. Case No. 16—Patient unable to' walk. Has used brace. No mother. Housekeeper decided the treatments caused too much bother. Case No. 17—Child removed to hospital for treatment. Improved, but is obliged to use crutches.60 Post-Infantile Paralysis Cases—Goodale The condition of patients who are listed at the present time as shewing marked improvement is as follows: Case No. 1—Slight disability. Case No. 2—Slight disability. Case No. 3—Slight disability. Case No. 4—Slight disability. Case No. 5—Slight disability. Case No. 6—Slight disability. Case No. 7—Slight disability. Case No. 8—Slight disability. Case No. 9—Slight disability. Case No. 10—Slight disability. Case No. 11—Cannot walk alotie. Some atrophy. Case No. 12—Cannot walk alone. Marked atrophy. Case No. 13—Slight disability. Case No. 14—Slight disability. Case No. 15—Walks with the help of a brace. Case No. 16—Walks with the help of a brace. Marked atrophy. Case No'. 17—Slight disability. Those listed as showing slight improvement present the following record: Case No. 1—Unable to walk. Slight atrophy. Case No. 2—Unable to walk. Case No. 3—Walks with assistance. Slight atrophy. Case No. 4—Slight disability. Case No'. 5—Bad arm case. Case No. 6—Unable to walk. Marked atrophy. Case No. 7—Unable to walk. Marked atrophy. Case No. 8—Walks with assistance. Case No. 9—Walks with assistance. Marked atrophy. Case No. 10—Bad arm case. Case No. 11—Unable to walk. Slight atrophy.Post-Infantile Paralysis Cases—Goodale 61 Case No. 12—Unable to walk. Case No. 13—Unable to walk. Case No. 14—Unable to walk. Case No. 15—Unable to walk. Marked atrophy. These tables convey to the reader a slight picture of the hideousness of acute anterior poliomyelitis considered in reference to its end results. Unquestionably the absence of atrophy in some of these cases is due largely to the attention which the Health Department physicians and nurse have bestowed upon the patients. The same is true of contractures. In one or two instances bad contractures have supervened, only, however, in the cases listed "discharged" where the mother has refused further attention. It must be borne in mind that this horrible array of crippled children is culled from a total of only fifty-five patients. What about the balance of the 281 cases reported during the epidemic, a few of which probably are now under the care of physicians, the rest shifting for themselves? This query occurred to the Department of Health about six months after the epidemic had ended. The answer was deemed worth the trouble necessary to procure it. Accordingly, the interne attached to the Ernest Wende Hospital house staff was detailed to examine carefully the condition of every patient reported during the epidemic with-instructions to record his findings on a blank designed by Dr. Sharp for the purpose. Some task. In all 205 persons were examined (which figure includes those under the care of the department nurse). Of these, only fifty-two failed to exhibit absolutely any trace of their late affliction, approximately twenty-five per cent. The treatment of post-infantile paralysis is mainly preventive and corrective. During the acute stage it was often necessary to employ sand-bags, splints or removable casts for a portion of the day, especially when contractures appeared early. So soon as the tenderness had disappeared, however, massage was used in an endeavor to keep the muscle tissue in good condition pending the possible return of nerve function. It must be continued over a long period of time, as in many cases improvement62 Post-Infantile Paralysis Cases—Goodale is slow, weeks and months intervening before progress is noticeable. This measure alone, in the majority of cases, if intelligently-applied in time, will prevent deformities. "Where contractures exist, however, splints or casts are often indicated. These should be easily removable for the reason that a muscle cannot be kept constantly on the stretch. Electricity is often valuable, the Faradic current preferred, if the muscles will respond. Often, however, they will react to a Galvanic current only, which should be used rather weak. Many of the neglected cases require the services of a trained orthopedist. Under such supervision, joint fixation, braces, crutches and tendon transplantation may afford relief and often cure. An epidemic of infantile paralysis, analyzed, is a thing of horror. The analyst, to drive home his point, has scant need for the wiles of the statistician or the methods of the "sob" reporter. It is a tale, simple and unadorned, of a helpless citizenry attacked by an insidious, unknown foe. Many a survivor is left to work out the biblical injunction, "Thou shalt earn thy bread by the sweat of thy brow," with an impaired muscle or mayhap a brace or a crutch. More power to the men who are engaged in a hunt for the cause and the cure of acute anterior poliomyelitis. The moral and financial support of every community throughout the universe should be theirs, unasked.Left arm involved, but improving. Right arm shows considerable atrophy. Wrist drop. Fingers contracted.Muscles of spine badly damaged. Arm also involved. Patient unable to assume a strictly upright position.Both lower limbs paralyzed. Double foot drop due to peroneal paralysis. Able to stand but unable to walk. Atrophy marked in right leg.Paralysis of external rectus muscle of the left eye. Lower extremities also involved. Patient can sit but not stand. Right arm also affected.Right leg paralyzed below knee, left lower extremity paralyzed from hip down. Able to stand but unable to walk. Patient improving. In the beginning could not sit up.Extensive shoulder girdle paralysis. Hand and wrist normal. Both legs involved from hip downward. Has been unable to walk since attack.PRESS OF THE BUFFALO COMMERCIAL, BUFFALO. N. Y.• . - \ . • •; - • • - - • v-^ I 1 • - ■M . \ - ■ ' - " v..--". ■ ' I * ' ■ I 'Pi % V ,__^ . r V.. - ___ -______: " - - - , - ; 1' ! ' > - / ; * ■ . ' .. .. •-.:.• .V '■■;': • - ■ . : ■ ■ • . ___. . _ ^ '