AROUND THE SITTING ROOM TABLE

INFANTILE PARALYSIS.

December 1 1910
AROUND THE SITTING ROOM TABLE

INFANTILE PARALYSIS.

December 1 1910

INFANTILE PARALYSIS.

IN a ward in the Hospital for Sick Children in the City of Toronto there are, or there recently were, ten little children suffering from infantile paralysis. Some were dying. A few were recovering. Those that will, must be afflicted for the rest of their lives with the mark of the disease: a paralyzed limb, an affliction of the organs of sight, or hearing, or speaking—some mark.

In the streets of Montreal a little girl was playing tag this summer. Suddenly she was seen to take no interest in the game. She lay face down on the ground, crying. She did not know why she was crying but she felt “sick.” They took her home and nine days afterward she was dead. People said it was infantile paralysis.

The mother of twins on the same street read about it and took every pains to see that the twins should not be exposed to contagion. They were still in arms and had never been out of the house, but one of them stiffened with the disease and died—infantile paralysis.

The same story has been told in almost all the large cities in Canada, and in the country places too.' Grown people have been attacked and have died. The victims have been of the rich and the poor, healthy and sickly, country people and city people. Where the germ originally comes from is a mystery. How to take precautionary measures has been only guessed at. In view of these things, therefore. John B. Huber’s article in the American Revieiv of Reviews on “Infantile Paralysis a Menace,” should be read by everyone.

Before 1907, he begins, epidemics of infantile paralysis were rare in this country. There was one in New Orleans in 1841 ; and again, about thirty years ago, the disease was pronounced, but it was otherwise not especially noted until the beginning of the present century. There was a marked epidemic in Sweden in 1905 ; two in Australia in 1903 and 1908; and an extensive epidemic in Prussia in 1909. It is not likely that other European countries have wholly escaped. The disease has for several years past been prevalent in Scandinavia.

During the past four years infantile paralysis has prevailed throughout this country and probably but few localities have been altogether exempt. In a single epidemic which visited New York City in 1907, 2,500 cases were reported. The southern Hudson region, with the surrounding lowland sections, suffered also. There were in that year, moreover, cases in 136 of the 354 cities and towns of Massachusetts, the infection having been relatively much more prevalent in small towns than in cities and large towns. The disease in its epidemic form is emphatically one of hot weather, prevailing most in July, August, September and October. Cases have been noted to develop after a hot, dry ‘spell.’ Nevertheless it seems warm countries do not suffer as much as those more northerly.

Epidemics are 'bound to subside with the first sharp frost.

Dr. Simon Flexner, who has made brilliant and pregnantly beneficent researches regarding this disease, observes that about the beginning of 1907 there arose a pandemic (a world-wide, or at least a very general) spread of infantile paralysis; and it is significant to him that the original foci of the epidemic disease of the summer of 1907 in the United States were along the Atlantic seaboard, the two communities most seriously affected having been in and about Greater New York and Boston. Now these two great centres receive first and in the most concentrated way the northern and eastern European immigration; and since the last established endemic (or indigenous) forms of epidemic infantile paralysis, recorded in the last decade or more, have been developed on the Scandinavian Peninsula, it is most suggestive that (after New York and Boston) the second large isolated outbreak of the disease among our people occurred in and about Minnesota, a middle-west region receiving very many Norwegian and Swedish immigrants.

THE Census Bureau at Washingon has recently stated its finding, that in 1909 there were reported 569 deaths from infantile paralysis in the death-registration area of the United States (which area comprises above 55 per cent.' of our total population) ; of these 569 deaths, 552 were of white and only 17 of colored persons. The deaths thus reported were widely distributed, indicative of epidemic prevalence in many parts of the country. These data, be it emphasized, relate only to registration sources; in the non-registration States the deaths thus reported are only for the registration cities contained therein.

The Department of Health of Pennsylvania reported on September 17 last, 658 cases of infantile paralysis in 45 of the 67 counties of that State ; 79 of these cases were in Philadelphia.

On September 3 last, it was reported from Springfield, Mass., that the steady increase in the number of cases of infantile paralysis had become a matter of deep concern throughout that State. The first case this year in central New England was, it appears, reported on May 21 ; and this patient was promptly quarantined. The middle of June saw thirty or more cases in Springfield; and early in July an epidemic was established. By September 3 central New England reported 250 cases and the deaths to that date aggregated 100; it was then felt that the sufferings of those in this region were unequaled anywhere else in the Union. It would seem that Springfield has been the centre of this epidemic ; outside a radius of twentyfive miles from it the number of 'ases has been inconsiderable. Hartford, twenty-six miles from Springfield, with a larger population, has reported only a few cases. Since gatherings of children were regarded as dangerous, playgrounds were practically deserted during the past summer ; and Sunday-school sessions were discontinued. The opening of the Springfield public schools was postponed to September 19; in other towns like postponements were made. Even then the attendance was much curtailed, many parents having sent their children from home.

BUT of what nature is the disease infantile paralysis, or acute anterior poliomyelitis? It is an infection characterized by inflammation especially of motor neurones in the anterior horns of the spinal cord, though the medulla and pons above and even the cerebrum may be involved. A very succinct definition is that of Drs. Chapin and Pisek: It is “an acute inflammatory process taking place in the anterior horns of the spinal cord, accompanied by a sudden and complete paralysis of various groups of voluntar}" muscles, followed by a rapid wasting of the affected mus-

cles.” The motor neurones are the nerve or ganglion cells (telegraph stations, as it were), concerned in muscle development and muscular movements; in this disease these neurones, if the inflammation proceeds without arrest, degenerate, liquefy and shrivel up: the nerve fibres emanating from them and which in health convey their messages to the given muscles, degenerate and atrophy. This process may go on to complete destruction of these precious tissue elements; or it may happily be arrested at any stage. If checked early, repair may ensue, and the neurones, with their fibres (their telegraph wires), will regain fairly well their normal condition and function. If unfortunately the inflammation is progressive, the size and shape of the spinal cord at the points involved are contracted and pathologically so altered that the muscles concerned become paralyzed, atrophic, degenerated and incapable of their proper and normal function. When recovery does take place these muscles are apt to remain small, perhaps throughout lifetime.

The little patients suffer also retarded bone growth, deformitv of the joints involved, “drop-foot.” sometimes lateral curvature of the spine, sluggish circulation, and generally impaired bodily nutrit:on. From S to 15 per cent, of these patients die: and three-fourths of those stricken who survive are more or less crippled for life. The disease is generally acute, and by far the greatest number of its victims are infants and children from one to five vears of age—though not all; deaths from infantile paralysis at sixty and sixty-three have been recorded. The outlook is thus fairly good as to life; yet the severity and fatality of the infection fluctuate widely in various epidemics and localities : and. taking it all in all. infantile paralvsis is sufificientlv disastrous and melancholy to give the medical profession anxious consideration, as it should give the public grave concern.

During the incubation period of this

disease (from the time oí having incurred the infection to the development of the paralysis) the patient may have prodromes, difficult to detect in little children, who may not be able to indicate the nature of their sufferings; such premonitions will be changed disposition, restlessness and irritability and, perhaps, on the other hand, apathy. The distinct invas:on then begins suddenly with a high temperature and the symptoms of an acute infection: sweating; a pain in the

back and limbs; neckache and headache ; the child will not be able to sit up and hold up its head; in many cases there are digestive disturbances; very shortly there supervenes paralysis (perhaps ushered in with delirium). especially in the leg muscles. Or a definite group of muscles may be involved ; or but one extremity or the trunk or the upper ext-emities. Permanent paralysis usually affects the legs, rarely the arms. Perhaps such paralvsis is preceded by muscular twitchings, and sensitiveness when handled. Other symptoms, such as squint, will vary according to the part or parts of the nervous system affected : blood changes are marked in this disease. Infantile paralysis has been mistaken for meningitis and for rheumatism.

AS to the causation of infantile paralysis: Before 1007 phvsi^ cians concluded (though they could not nuite prove it) that in perhaps two-thirds of the cases infantile paralvsis is infectious, the remaining third being attributed to such factors as falls, antecedent enervating diseases (such as measles and the like), or hemorrhage into the spinal capillaries. Inferences as to infection in infantile paralysis were fumvWd bv epidemicitv in the disease. th° nature of its clinical course, the Ugt that oftentimes more than one child in a family was attacked, and especially the age-incidence : for almost all acute infections (measles, scarlet fever, whooping cough and the like) are

generally childhood diseases; adults and the aged rarely succumb to them because such attacks in infancy are likely to have conferred lifelong immunity upon the individual.

But in the light of our knowledge up to date it is extremely likely that such factors as falls, antecedent diseases, and the like are not essential to the development of infantile paralysis, but have been predisposing agencies, making the tissues involved vulnerable to a specific virus. And besides these predispositions there are others which physicians have come to consider antecedent to infantile paralysis, and still others which accompany it and emphasize its serious nature. Such are wounds, insect bites, sore throat, coryza, tonsilitis, pneumonia, earache and “running ear,” diarrhoea and other digestive disturbances.

THERE are other considerations of causation: Data collected in Scandinavia indicate especially well that the virus can be carried by intermediate persons (not themselves ill) to the healthy from the stricken, and from patients not frankly paralyzed but suffering from slight (socalled abortive) attacks of the disease. The incubation period in infantile paralysis has been found to vary from five to thirty-three days, the average being eight to ten days ; there has thus obviously been opportunity for the transfer of the disease across the Atlantic, before its detection in quarantine was possible.

Physicians in Massachusetts and elsewhere who have studied the disease, have concluded that the virus may be conveyed by the bite of insects ; and, in the light of our recent knowledge of insect transmission of many infections, time will, no doubt, establish the correctness of this observation concerning infantile paralysis. Dust seems to be provocative. In one epidemic of 150 cases, investigated by Dr. R. W. Lovett, of Boston, 62 of the patients had been swimming

or wading in sewage-oontamirated water before coming down with the disease.

In Massachusetts there were some instances in which there was sickness, paralysis, and death among domestic animals and fowls, coincident with the epidemic outbreaks among human beings ; in 34 out of 87 families this phenomenon was observed. In Washington the Public Health and Marine Hospital Service has been examining a number of dead chickens furnished by Dr. J. L. Lewis, of that city, who had been attending a case of infantile paralysis; I have not yet seen the results of this examination, which was to ascertain whether the disease was communicated to the patient from the chickens, which were taken from his farm; they had taken sick, and the patient was caring for them immediately before he came down with the poliomyelitis. The patient is a breeder of chickens; these fowl died and the breeder then himself succumbed to what was diagnosed as infantile paralysis. It is here noteworthy that in the experiments of Dr. Flexner, presently to be considered, attempts to implant the virus in such available warm-blooded animals as guinea-pigs, rats, mice, dogs, cats, sheep, cows, goats, pigs, chickens, pigeons, and the horse, were not successful ; only in the monkey was the transfer of the virus successful.

In the epidemic in and about Springfield it was observed that the disease did not especially flourish among the poor, since there were no cases in the most congested tenement districts ; it was considered that many well-to-do children escaped, because they were taken from home during the summer. On the other hand, it has been held that the poor do suffer most, and that the cases among the wellto-do have been in districts bordering upon areas of congested tenements, which the poor occupy.

Thus in infantile paralysis we have to deal with an infection of a contagious sort (contact infaction) ; the

virus is present in the secretions from nose, throat and mouth, especially in the pharynx ; possibly also it exists in the discharges of patients. Dr. Flexner observes: “Nor can it be affirmed that still other avenues of infection (as the skin, the organs of respiration or the digestive tract) do not exist, for the entrance of the virus into the central nervous system.” It is probable that the infectivity does not extend beyond the acute period (when the fever and other symptoms are intense).

OUR evidence thus far has been circumstantial ; and, indeed, up to within the last several years a completely scientific demonstration of the infectious nature of infantile paralysis was not forthcoming. But early in 1909 Drs. Landsteiner and Popper, in Germany, successfully inoculated two monkeys with the spinal cords taken from two fatal human cases of poliomyelitis ; in both these animals spinal cord lesions akin to these in the human being were found on autopsy.

In September, a year ago, Dr. Simon Flexner and his colleague, Dr. Paul A. Lewis, of the Rockefeller Institute in New York City, obtained from physicians the cords of two children that had unfortunately died of acute anterior poliomyelitis ; in these cords the anterior horns exhibited the characteristic gross and microscopic evidences of the disease. Transmission was then made to monkeys, a creature more nearly related to man than others. After ether anesthesia, inoculation was made in the brain of these simians through a trephine opening; the injected material consisted first of emulsions in salt solution of the two human cords ; and later of emulsions of the spinal cords of the monkeys that had developed paralysis after injection of the first emulsion (that from the human cords). The spinal cords in six series of monkeys thus inoculated seriatim showed with-

out exception lesions similar to those of human poliomyelitis.

One must here note that a single successful inoculation with human virus resulting in experimental poliomyelitis could not establish the case for science, because the result might have been due to a transferred toxic body; but in the superb experiments of Flexner and Lewis the transfer of the active, essential, specific virus of infantile paralysis was regularly successful. Hence by these and other equally conclusive experiments, one cannot now doubt the infectious nature of acute anterior poliomyelitis; the pathogenicity of the disease is established.

BUT now as to the nature of this virus which is responsible for infantile paralysis or acute anterior poliomyelitis. It is at present invisible or at least indistinguishable under the microscope (that instrument which now discerns with ease objects 1-50,000 of an inch in thickness). A filtrate of the inoculated fluid discloses under the dark-field microscope innumerable bright, dancing points, devoid of definite size, not truly mobile, of rounded, oval form ; but one cannot certainly affirm these are the pathogenic germs.

The microorganism responsible for infantile paralysis is neither a bacterium nor a protozoön, such parasites ( respectively vegetable and animal) as have been isolated as the infective agents in most of the infectious diseases ; yet it must be considered a living organism from the fact that infinitely minute quantities of it suffice to carry infection through an indefinite series of animals—25 generations at least, representing 25 series of monkeys. The infective agent of infantile paralysis belongs to the class of the minute and filterable viruses that have thus far not been demonstrated with certainty.

Nevertheless, the smallpox virus, for example, is just such a virus; al-

though it still remains indistinguishable under the microscope, a vaccine has been evolved from this virus by which that dreadful scourge has been practically banished from the face of the earth; wherefore there is no reason in logic or in science why a similar immunizing and curative agent against the disease which has caused such pitiful suffering and death in little children shall not now in very good time be forthcoming. Every man and woman of normal mind and heart will rejoice in such an outcome.

Infantile paralysis has been made a reportable disease in Pennsylvania, as it certainly should be throughout the Effiion. The Iowa State Board of Health has ruled that all cases of infantile paralysis, or suspected cases, shall be reported by the attending physician or the parent to the local Board of Health ; it recommends the quarantine of all cases for at least two weeks after the beginning of the disease, and thorough disinfection of infected premises after the termination of the disease; and, noting that the infectious material is found in the secretions of the nose and mouth of infected persons, it recommends the use of sprays or gargles of one per cent, hydrogen peroxide solution to prevent the disseminating of the disease, and that all a patient’s discharges be disinfected by means of mercury bichloride or carbolic acid.

With increased knowledge of the disease earlier diagnosis will be made ; this is especially desirable in infantile paralysis ; for when an immunizing agent has been perfected, the earlier in the disease it is administered the more effective it will be (as in diphtheria and in infections generally).