Paralysis: The New Epidemic
Infantile Paralysis is epidemic in some parts of Canada. The germ attacks rich as well as poor, adults as well as children. In Ontario last month half the cases were fatal. Dr. MacMurchy is able to give our readers the latest developments concerning this dread disease direct from the great specialists, having recently attended a medical congress where the question was discussed. It is now thought that the germ is carried mainly by the stable fly. Dr. MacMurchy says, Never let a fly rest on an infant.
The toll of the victims of tuberculosis grows smaller every year. When shall we be able to say this of that disabling disease which now counts its victims by the thousand where it used to count them by the couple. Theirs is the sad fate of the disabled, who must go on life’s rough way never able to walk as well again, never able to skate at all, or to dance or to run. It is hard.
The increase of acute anterior poliomyelitis to epidemic proportions has forced every medical laboratory to study it with the industry of Sisyphus, the keenness of Sherlock Holmes and the patience of Job. A little gleam of hope came witjPlexner’s results in procuring passive immunity, but not much. Still we shall know some day.
Nor is the treatment of the sufferers from this disease as heart-breaking and hopeless as it used to be. It is wonderful how far and how long recovery may go on, especially if the patient is under skilled medical care from the first. The paralyzed muscles may be re-educated, growth may proceed, modern appliances and modern surgery may conceal or minimize the deformity, until disablement disappears altogether or is reduced to a minimum. Thus the disease is in a manner conquered. Sir Walter Scott was one of the conquerors. Stricken by it in early infancy, he was sent to
his grandfather’s farm to recover. A Scotch shepherd took charge of that baby genius and carried him out every day to nurse him back to health among the hills, laying him down on the plaid, and encouraging him to use his limbs. It will be remembered that only a slight limp remained.
The first well-recognized epidemic of acute anterior polio-myelitis was in Sweden in 1881. The first epidemic in England was in 1897. Many American epidemics occurred where there were Scandinavian immigrants. Fivesevenths of all cases so far reported have occurred in the United States, the first epidemic being in Massachusetts and Vermont in 1894. From 18801884 only 23 cases were reported in the United States, a number which gradually increased to 349 in 1900-1904. Then came the destroyer in overwhelming strength and suddenly. From 1905-1909 there were 8,054 and in 1910 alone there were 5,093. Flexner thinks there have been at least 20.000 cases in the United States with 10,000 or 15,000 disabled. Twenty-eight cases of infantile paralysis were discovered in Buffalo, August 1, 1912, and three of these died in one day.
Our own Commission of Consérva-
tion has collected some interesting statistics as to Canadian cases from November 1, 1909, to October 21, 1910. The figures as given by Dr. Hodgetts to the Canadian Medical Association are as follows:
Dominion of Canada:
Ontario .............. 354
Quebec .............. 187
British Columbia...... 48
New Brunswick ....... 12
Nova Scotia.......... 6
Prince Edward Island.. 1
It is certainly a disease of the Temperate Zone and of the colder part of that zone, and while the worst season is from May to November, yet it may and does occur in any month of the year.
1910 was in a terrible sense a “wonder year” for epidemic poliomyelitis.
In that year it appeared all over the world, as it were. Epidemics occurred in Britain, Canada, Cuba, the United States, Germany, Austria, Switzerland, Belgium, Russia and Denmark. A remarkable epidemic occurred in Naura, a small island in the Pacific, 160 miles from the nearest land, where there were 700 cases and 30 deaths though the total population was only 2,330.
The disease itself was first described by an English physician, Dr. Underwood, in 1774, but it was not till I860 that Heine wrote of the spinal cord as the place where the damage occurred.
Of those attacked by this enemy ten to twenty per cent, do not survive. About 80 per cent, suffer from paralysis and of this 80 per cent, only about one out of four recovers perfectly. All the rest are more or less disabled. In Ontario in September fifty per cent, of the. cases were fatal.*
The majority of cases occur from three to five years of age, 75 per cent, of the total number being under four years of age, and more males are afflicted than females. Still, there are many patients under three years of age, and the number of adults varies from one per cent, to 15 per cent, or more of the total number of cases. A number of cases have occurred after the age of fifty years, but the rule is that age increases resistance.
No one who has considered the mat-* ter at all now doubts that the disease is communicable. This was proved by Flexner and others in 1909. It is certainly caused by a living organism, probably too small to be seen even by the aid of the best microscopes we have, certainly small enough to pass through porcelain, or rather to be driven through porcelain as we drive fluid through a filter.
And what is more, that virus, whatever it is, has been found in the blood, yin the cerebro-spinal fluid, in the glands, in the cells of the nervous system and in the discharges from the nose, the mouth, and probably in the other discharges of the body of any patient.
The period that elapses from the time that the infection is “caught” to the time that the symptoms appear is not surely known yet. But it is probably from 1 to 14 days, though it may even be 30 days, and in monkeys, which also suffer from this disease, it is sometimes as long as 46 days. Rab-
bits probably suffer from the same disease and there is some evidence that poultry do, and possibly horses also.
One case is on record where anterior poliomyelitis occurred twice in the same patient but this is almost unknown.
The victims of this disease are not
among the poor, or delicate. Often the vigorous and healthy are attacked and those who have comfortable homes and good care. Six years ago the head of one of the largest industrial corporations in Canada was a victim. So was in that epidemic a professor in Queen’s College, Kingston.
Nor is there much within the first* twenty-four hours to rouse anxiety. There may be vomiting, there usually is fever, often headache, always some weakness, tiredness 'or prostration. Sometimes the next day the little patient feels better and wants to play and
run about. Better not. It is possible that nature is making a brave fight and with rest and careful watching and nursing will rout the enemy. We have reason to think that in some cases where the patient is better for a day or two and then the dreadful paralysis appears, that the paralysis is really a relapse, from which rest might have saved ‘the patient. Anyone who is really indisposed, young or old, should ‘‘make haste slowly” about returning to the usual strenuousness of modern life. There is another important group of symptoms—the nervous group. Restlessness, irritability and excitement, with little or no cause, always attract the attention of the wise and’ watchful head of affairs, and where the foolish precipitate a struggle for authority and the harsh resort to punishment, the more experienced and more sensible mother wull ^soothe without capitulating to every whim and will give a comfortable bath and put the poor child to bed, thus perhaps averting serious consequences, and at least giving Mother Nature a chance to exercise her supreme powers.
Pain, unhappily, is almost always present and may be soothed by warmth, especially by hot applications, sometimes even by the continuous hot bath, where the child is, as it were, put to bed in a warm bath and so saved a deal of pain and discomfort. Pain is felt in the head, the neck, the back, the limbs, even the face—one or all of them.
Paralysis comes on usually about the second, third or fourth day. It may be delayed till the seventh or eighth day. It appears sometimes in one limb and then in another. Almost always there is some recovery, often a great deal, especially in the first few7weeks.
A troublesome and distressing symptom is contraction of the muscles so that the limbs cannot be extended, and sometimes so that the back is curved and cannot be straightened. This is due more or less to spasm of the muscles, and gradually improves, though almost imperceptibly at first. Nothing gives more comfort and joy to the patient, the family, or the physician than the gradual regression of this and other symptoms which so greatly threaten not only the bodily comfort of the poor patient,
but the peace of mind and the happiness of everybody concerned.
Watch for muscular weakness. Often, because the little patient can manage to move the limb in bed, probably from the hip only, the real condition is not recognized, till he gets out of bed, and the poor paralyzed limb hangs useless and lifeless, refusing to support the child. The natural vigor with which a child moves and wriggles, and often objects to examination is a tremendous comfort when all are wondering whether we have influenza or infantile paralysis to fight, and when the child dislikes to be touched and vet its efforts are feeble, it makes one anxious.
On September 1, 1911, acute poliomyelitis was made compulsorily notifiable in London, England. It is notifiable now in Canada, the United States and in civilized countries generally.
No subject at present occupies more attention than this. Governments and laboratories have issued splendid reports dealing with .the whole question. Among these are the reports of the work done by Dr. Simon Flexner, in
New York, the Blue Book issued by the Local Government Board in London in 191.2, and those issued by the Boards of Health in Pennsylvania and Massachusetts.
The British Medical Association gave much time to it this year at their annual meeting, and at the International Congress of Hygiene and Demography in Washington on September 26, a whole morning was given up to the discussion of this one disease. It was a meeting of giants. The great hall in the Pan-American Building was crowded to the doors, and on the platform were such citizens of the medical world as Flexner and Levaditi. The interest was breathless and when Dr. Rosenau announced that his recent researches went to prove that the stable fly was probably the chief carrier of the infection a sensation ran through the audience. There are a good many facts which seem to corroborate Dr. Rosenau’s theory.
Preventive medicine is presented to the readers of this magazine as the only hope for dealing with anterior poliomyelitis. We shall never cure it once the enemy has massacred the good gray
cells in that part of the spinal cord which gives the child the gay and glad activities of play and work, and the adult the power of independent motion. But we can do something to prevent it now and we shall do more in the future.
Every question concerned with this disease arouses a fascinating, almost a painful, interest, but when one comes at last in sight of the possible mode of infection one’s interest reaches white heat. There is a cause. But it is “the pestilence which walketh in darkness.” How does it select its victims and where does it strike them that we might protect them from its murderous and cruelly disabling attack?
It has been proved that in monkeys affected with the disease, the virus passes from the central nervous system to the nasal mucosa.
It has been proved that if the virus of the disease be implanted on the nasal mucous membrane of a healthy monkey then the monkey contracts the disease, especially if there is any crack or scratch or sore place there. The amount of the virus required is small, about the fiftieth part of one drop.
The following causes have been mentioned :
1. As to vermin — it is not likely that they spread the disease. Thousands of cases are reported where ver min could not have had anything to do with the infection. But the fly is a different matter. The virus remains active when carried on the feet of a fly for 48 hours or more. There is no reason why, if flies are in the house or the sick room they should not come into contact with infective secretions. The fly is a carrier of infection. Kill the fly. Not one fly should ever be allowed in or round a house. This is imperative. Never let a fly touch a baby.
2. Food. Unlikely. Certainly the virus is neither water-borne nor milkborne.
y 8. One physician reports that nearly all the patients affected in a large epidemic had been wading in ice-cold
water shortly before the onset of symptoms. This is probably a mere co-incidence.
4. Bathing in water contaminated by sewage. In the Massachusetts epidemic of 1909, 150 cases were investigated and 62 of these had been swimming or wading in water more or less contaminated by sewage.
Every public bath should have the water in it frequently changed. Slime should never be allowed to collect. Chlorination should be carefully done daily or oftener, so that the water may be free from infection. Specimens of the water should be examined by a competent bacteriologist. Diluted sewage is dangerous to bathe in.
5. Animals. There are on record several cases where paralysis in horses, chickens and rabbits was followed by infantile paralysis in the children of the house.
6. Diarrhœal. It is thought that inasmuch as diarrhœal diseases are most prevalent when infantile paralysis is most prevalent, i.e., in the warm weather, that some connection may exist between the two. This is possible, but not proven.
7. Contact with a patient. There is now quite sufficient evidence to make us think that the disease is conveyed from one patient to another. Therefore the patient should be isolated with a nurse or other person able to give all the necessary care and nursing. Visitors should not be allowed. It is better not to let the other children in the house go to school for about fourteen days. All the patient’s excretions should be properly disinfected, especially those of the nose and throat. The mouth and nose should be gargled and cleansed with an antiseptic solution. Handkerchiefs should be boiled. It would be better if cheese cloth were used instead of handkerchiefs, and burned afterwards. The nurse and the physician should observe the usual precautions against infection or carrying infection to others. The use of antiseptic throattablets (as aldoform or formamint) and of antiseptic nose-wool is g çqpyepient
and sensible precaution. Menthol and hydrogen per-oxide preparations kill the virus.
After the attack is over the health authorities should disinfect the house with formaldehyde. This should also be done in any school where cases have developed among the pupils and perhaps the school should be closed.
8. Carrier caaes, that is, persons who harbor the virus in the throat and nose and so may and do transmit it to others, though not suffering from the disease themselves, are known to exist and undoubtedly are a great source of danger.
9. As to school infection, the evidence is not conclusive, though there are many cases that almost prove it. On 'the other hand, there are facts which seem to show that school infection cannot be an important cause. The subject needs further investigation, and in the meantime, the patient should not go back to school for a considerable time—perhaps three months, and every vigilance should be used to watch against school infection. Contacts, i.e., other children in the house with a patient should not attend school for fourteen days after the onset and then only if the patient has been isolated.
10. Dust. There is not a little evidence that dust is a possible source of infection. At Cornell University the dust on the floor of rooms in each of which was a patient with anterio-poliomyelitis was used to inoculate monkeys, and these animals in several instances developed the disease.
Further. A great many cases have occurred on main roads and dusty thoroughfares, not in houses where lawns or fields intervened between the house and the road. This is a good argument for good roads, street cleanliness, for oil and other anti-dust remedies, for the nightly flushing of asphalt pavements, for frequent waterings and for damp dusting, perfect cleanliness and other things characteristic of good private and public house-keeping and city-keeping.
Lastly, a few words must be said on the nursing and medical care of the patient. First of all, we need the best medical skill. There will be found in every large city some one or two doctors who have made more or less of a specialty of infantile paralysis, and the good family physician will be eager tn utilize the special skill of such a consultant. It does make a difference to have such aid as this. With him and the family physician the medical care is assured. As to the nursing, this will be carefully directed by the doctor, but a few general hints may not be out of place here.
The bowels need to be cleared out—it helps to carry off infection. All the water, lemonade, orangeade, etc., that the child can take between meals will help in the same way, carrying off infection by the kidneys and the skin. A warm cleansing bath daily is necessary.
Perfect rest and quiet in a cool, wellventilated room, somewhat darkened, no visitors at all, but a cheerful, pleasant atmosphere, is of the first importance.
As soon as the fever and nausea have subsided good nourishment is also of the first importance. Milk and eggs in many attractive forms, well-cooked cereals and vegetables and fruit, and some meat and a few sweets. Keep up the child’s interest in his food.
Keep the patient comfortable but cool if the weather is warm, and remember, if hot water bottles are necessary, that sometimes while the case is acute, the skin is a little insensitive. Bewrare, because this means the child may be burned and yet not feel it. So you must watch.
Never have the patient lying on the hack. Turn frequently to either side and persuade to lie on the face. It lessens the congestion in the spinal area. An ice-bag to the head and spine is helpful.
The greatest single resource we have to combat the paralysis is to watch constantly and eagerly with the child the return of every atom of power or move-
ment. Make a great deal of it, and get the child absorbed in using the newlyrecovered power, but rest often, often. Never tire out the slight returning strength. Keeping up all possible movement of this kind will give really wonderful results. But it must be disguised to charm the child into working for it. Get a canvas bag from the bank with 100 new cents. If the child is old enough to understand give him one cent for ten kicks or 100 kicks at a tiny rubber ball, etc. The “kick” may be only one-quarter inch but the foot moved! With an infant, a big brightly colored rubber ball can be made the basis of an attractive game in which the partially recovered muscles may be used.
Massage, thorough, skilful and longcontinued, is an indispensable aid to the best results. A great deal can be done, however, by good rubbing by mother or nurse, carefully directed by the doctor, if the expense renders expert massage impossible.
The surgeon can give great aid in certain cases where the muscles have atrophied and the result is a serious handicap. Every year mechanical appliances are made lighter and better and are sometimes of great benefit. The latest improvement is celluloid splints.
Another important point is to watch that the weak muscles never get over-
stretched. Everyone has noticed that the toe in the paralyzed foot “drops” as it were and the patient has to hold the foot away up in order to walk at all. This may be prevented largely by always supporting the front part of the foot when sitting so that the toe is about two inches higher than the heel, and wearing a simple light splint in bed at night so that the foot is kept in that same position, with the ankle bent, and the toe on a higher level than the heel. If this is not done at night the weak muscles get overstretched by the faulty position and the weight of the bed clothes and so the foot _ drops, producing a permanent difficultyin walking. Patience and care in all these little details ultimately give in most cases a magnificent result, as is narrated, in the little pamphlet published by Professor Earl Barnes and his wife, called “A Case of Infantile Paralysis,” which concludes with these words, “Finally, while there i« no probable cure in most of these cases, there is possibility of improvement in all of them, and this improvement in details or as a whole, may come so close to cure as to be virtually the same thing. Nowhere in the long process of recovery is there any place to stop, nor any reason to be discouraged