Images Of Poliomyelitis
A Critique Of Scientific Literature
Presented here are two articles regarding the poliomyelitis epidemics in Massachusetts in 1908. They were published together. The first strongly presents the idea of virus causality and then an overview of the polio epidemics, and the second is the detailed analysis by the Health Inspector of the fairly localized epidemic in northwestern Massachusetts (Franklin County), which constituted over half of the polio cases in the state. Jim West's comments are in green.
From Boston Medical And Surgical Journal (7/22/1909) p112:
The Occurrence Of Infantile Paralysis
In Massachusetts In 1908
(Second Paper)Reported For The Massachusetts State
Board Of HealthBy Robert W. Lovett, M.D., Boston
TEXT Commentary by Jim West In pursuance of the policy inaugurated in 1907, the State Board of Health in 1908 continued the investigation into the occurrence and distribution of cases of infantile paralysis in the State of Massachusetts with especial reference to etiology. As in the previous year circulars were sent to all physicians asking them to report to the Board cases coming under their observation, and to physicians reporting cases, blanks were sent to be filled out. From these blanks the following data were obtained. The 1907 circulars sent out to physicians was a concept initiated in New York. It was designed to require the reporting of polio symptoms in terms of germ theory. This official policy preceded the science, because Landsteiner and Popper were not published until in 1909. Physicians seeing such cases were also requested to forward to Dr. Theobald Smith, pathologist of the Board, fresh specimens of stools from acute cases for bacteriological study with reference of course to etiology. It is not possible as yet to state the results of these examinations. The Board has already started on the investigation of these cases for 1909 which will follow much the same lines as those of the two previous years with especial efforts to obtain fresh stools for examination. Again the Board desires to express to the medical profession its gratitude for the most willing and helpful cooperation. Scobey states that in 1910 (Pennsylvania) both polio and pellagra were required to be reported by physicians as a communicable disease. The present paper will first present a brief abstract of the literature dealing with the epidemiology of the affection appearing since the last report (Boston Medical And Surgical Journal, July 30, 1908), and second an account of the features of the disease as occurring in the state in 1908. The serious epidemic which occurred in 1908 in Franklin County will be dealt with separately by Dr. H. C. Emerson, who investigated it on behalf of the Board. Abstract Of Important Literature Bacteriology and experimental production. -- The most valuable contribution of the year toward our knowledge of the disease has been made by Landsteiner and Popper, of Vienna,1 who have apparently succeeded in producing the disease in monkeys by inoculation. A boy of eight died of the disease on the fourth day. The autopsy showed typical anterior poliomyelitis. In the spinal cord and cerebrospinal fluid there were no organisms to be found and cultures were sterile. Parts of the spinal cord were then emulsified in salt solution and injected into the abdominal cavity [Note: Most historians write "intraparietal" as meaning into the abdominal cavity, but as the word can be applied to other organs, some have erred with "intracranial", 12/26/2005] of rabbits, guinea pigs, mice and two monkeys. In the first three named no paralysis ensued and the spinal cords were normal. Germ theory is promoted, though of low quality. (See HARpub analysis) Toxicology gets little play. See Dr. Scobey's history of the legal and intellectual enculturation of the medical mind regarding polio, beginning in 1907 in New York and then in Massachusetts.) The first monkey became violently ill on the sixth day and died on the eighth. He lay on the floor of his cage and his power to move his limbs was not investigated. After death changes typical of anterior poliomyeletis were found. The second monkey was noted to have lost all power in the hind legs on the seventeenth day. No paralysis was present on the twelfth, although it may have been present before the seventeenth in some degree. He was killed on the nineteenth day and again typical pathological changes were found in the central nervous system. From the spinal cord of this monkey inoculations were made into two other monkeys with negative results. The conclusion of these authors is that “ a so-called invisible virus, that is, one belonging to the class of the protozoa, is the cause of the disease.” With regard to the affection of domestic animals in epidemics of infantile paralysis, this was alluded to in the Rutland epidemic reported by Caverly2 in 1894 (horses and poultry). Dana investigated a hen with paralysis and found the bacteriology negative and the changes in the cord “acute infectious softening rather than myelitis.”3 It was noted by Wickman that in the Swedish epidemic of 1903 dogs were apparently affected in many instances with the children, but he was not convinced of the identity of the two affections.4 Free reported that pigs, and chickens were affected in the Michigan epidemic alluded to below. The attention of the State Board of Massachusetts has been called to the occurrence of infantile paralysis in a mother and daughter shortly after an epideffiic of “leg weakness” in the chickens of the household, and the matter is under investigation. Domestic animals with paralysis, concurrent with human polio, indicates poison causality, since according to orthodoxy, animals (aside from primates) do not get polio. Scobey comments. Pasteur,5 Foullerton and MacCormac investigated the cerebrospinal fluid of a case of poliomyelitis, finding in it mononuclear round cells. On staining, large cocci grouped in pairs and tetrads were found eleven clays and four weeks after the onset of the disease. Cultures were negative. Nine rabbits were inoculated with the fluid, of which some were paralyzed after about six weeks and the cord and spinal fluid of one of these was again inoculated into other rabbits with positive results. The inoculation from this series was negative. Cocci which did not grow were found in the spinal fluid of affected animals, but in the one cord examined there were no changes in the ganglion cells or about the vessels. The conclusion of these authors, that anterior poliomyelitis is not the result of a specific cause, is disputed by others on the ground that the experimental paralysis is not anterior poliomyelitis (Wickman, Landsteiner and Popper). Epidemics Recently Reported In Salem,6 Va., and vicinity occurred between June 2 and Aug. 10, 1908, 25 cases; the neighboring city of Roanoke, seven miles distant in close communication with Salem, escaped with 1 case. The cases all occurred in children under six, the youngest being thirteen months old. The death rate was 12%. In Salem,6 Va., and vicinity occurred between June 2 and Aug. 10, 1908, 25 cases; the neighboring city of Roanoke, seven miles distant in close communication with Salem, escaped with 1 case. The cases all occurred in children under six, the youngest being thirteen months old. The deathrate was 12%. In September, 1908, there occurred “a number of cases” in and about Whittemore, Ia.7 The following regulation was passed by the State Board of Health of Iowa: “ It is hereby ordered by the State Board of Health that all physicians and osteopaths practicing in Iowa shall promptly report to the mayor or township clerk all cases of poliomyelitis occurring in their district, etc.” In central Wisconsin8 in the summer of 1908 there occurred an epidemic with 60 cases in one of the smaller cities and 14 deaths. In central Pennsylvania the disease was active in the summer of 1907,9 100 cases having been seen in and about Dubois, and Sinkler10 estimated that in Philadelphia 30% more cases than usual were seen in that summer. Sinkler elsewhere speaks of the etiology as follows: “The nature and progress of the disease indicate clearly that it is due to an infection. It is obvious, therefore. that the micro-organism which produces the infection is one which is developed by hot weather. A large proportion of cases have some form of intestinal trouble... It is probable, therefore, that the micro-organism producing the disease has found its entrance into the system through the intestinal tract and thence to the spinal cord.” McCombs12 contributed a study from the Philadelphia Children’s Hospital of the disease as observed at that institution between 1903 and 1907 showing 50% more cases occurring in the summer of 1907 than the sum of all cases for the preceding four years. Forty-three cases in all were analyzed. Manwaring13 reported an epidemic of 30 cases in Flint, Mich., occurring in the summer of 1908 and alluding to14 other epidemics in the state, one in western Michigan reported by Ostrander and another in Chesaning. In the Flint epidemic the average age of affected cases was ten years. Of cases under ten all lived, between ten and twenty the mortality was 25%, over twenty the rate was 75%, corresponding to Wickman’s observations. Griffin15 described an epidemic of 20 cases in Oceana County, Mich., occurring between July and September, 1907. Twenty-nine cases were reported by Clowe as having occurred in Schenectady in the summer of 1907. There were 2 deaths in adults and 10 of the cases were seriously sick, 5 were classed as having made a complete recovery, 19 cases were less than four years old. Partial reports17 of the New York epidemic of 1907 have already appeared in various articles. It seems best to wait for the published reports of the committee appointed to investigate the epidemic, before analyzing the conclusions reached. In and about Vienna, in the summer of 1908, between the end of July and October, there occurred many cases of infantile paralysis, more according to Zappert18 than had been seen since 1895. He notes the large proportion of older children to be affected and speaks of it as a frequent occurrence in large epidemics. An epidemic occurred in Victoria,19 Australia, in theirautumnof 1908, selecting the months of March to June. It occurred chiefly in the most densely populated suburbs of Melbourne. There were 6 deaths in 135 cases recorded and the bacteriological findings are not sufficiently clearly given in the abstract, which alone is available, to be commented on. Byron Bramwell20 presented an analysis of 76 cases observed by him reaching over a period of years. One of two inferences is possible from the literature of the last year or so: either the disease is increasing rapidly in this country or the attention of the medical profession has been called to the disease and more cases and epidemics have been recognized and reported. Cases Reported In Massachusetts Occurrence and distribution. -- As against 234 cases of infantile paralysis reported in 1907 only 136 cases were reported in 1908. It is interesting to note in this connection that in 1907 444 cases of cerebrospinal meningitis were reported, while in 1908 there were only 183 cases. It was noted in the previous report that the two diseases, however, reached their maximum at different seasons. In 1907 the cases of infantile paralysis in their distribution in a general way corresponded to the density of population in the state, grouping themselves as a rule about the centers of densest population, and only in and about Pittsfield, where some 28 cases occurred, was there evidence of any marked epidemic. In 1908, however, the grouping of cases was largely different and bore slight relation to the density of population, and as a rule where the disease was prevalent in 1907 it was rare in 1908, thus corresponding to the conclusions reached by Scandinavian investigators that regions severely affected one year were for a while comparatively immune. As against 28 cases in the western end of the state in 1907 there were only 3 in 1908. In and about Lowell, Fall River and Haverhill there were in 1908 as in 1907 apparent slight centers of infection. About half (69) of the cases reported in the state occurred in Franklin County, the remainder (67) being distributed through the state. Cerebrospinal meningitis, however, in the year 1908 showed practically the same distribution as in 1907, in general being grouped about the densest population. These comparisons are made because cerebrospinal meningitis is an infectious disease apparently mildly contagious 21 affecting many children, and manifested in the central nervous system. Presenting these points of similarity it has been thought that its characteristics might possibly in the future throw some light on the disease under consideration. For purposes of simplicity the epidemic in Franklin County will be dealt with separately by Dr. Emerson and in the following analysis will be considered only the cases occurring in the state at large. The two analyses taken together will give the occurrence of the disease in the whole state. The distribution of the 67 cases may be seen in the map. I found no map in the publication. A map would make the graphic correlations between "downstream", "industrial", and "industrial pollutants" very obvious. So I have obtained a map for this era (See Map Of Franklin County). Contagion been so carefully studied in the epidemic that it will not be dwelt on here. Traumatism. -- In one case a history of exposure to dampness was given and in 9 cases histories of trauma preceding the disease. These histories, however, were in many instances vague and unreliable. Season of onset. -- Cases occurred as follows: January; 1; February, 1; March, 1; May, 2; June, l; July, 9; August, 11; September, 14; October, 15; November, 7; Date not given, 5. The season of onset does not differ materially from that in 1907, but does differ essentially from the season of onset in Franklin County where it was as follows: March, 1; April, 1; June, 6; July, 28; August, 26; September, 5; November, 2. Age. -- The largest number of cases (19) occurred between the ages of one and two and for the years from two to eight there were reported from three to eight cases for each age, after this the reported cases were one or two a year up to sixteen. There were two adult cases reported, one twenty-one and one forty. Sex. -- There were 39 males, 26 females and 2 not stated. As to other factors of possible interest in the etiology, 38 lived in detached houses and 27 in tenements, while 2 were not stated. Of the cases in tenements, 12 of the patients lived on the first floor,10 on the second, 4 on the third and 1 in the basement. Sanitary conditions were described as excellent in 24, good in 20, fair in 16, bad in 5. Symptoms. -- In 54 cases fever was present, the temperature ranging from 100 to 104. In one case no fever was present. In 12 cases no record given. Brain symptoms occurred in 15 cases. There was usually delirium during the febrile state. Vomiting is recorded in 21 cases, constipation in 20, and diarrhea in 8. Retraction of the head present in 10 cases. Pain is recorded in 46 cases, absent in 2. The pain was usually along the distribution of the paralysis and did not, as a rule, subside at once after the acute attack. Incontinence of urine and feces in 2 cases, incontinence of urine in 1, retention and later incontinence of urine in 1.
Relation Of Beginning Of Paralysis To Onset Of Fever Paralysis preceded the attack by two days 1 Occurred on the same day 5 On the next day 6 Two days later 11 Three days later 13 Four days later 8 Five days later 4 Six days later 1 Seven days later 3 Eight days later 1 Ten days later 2 Two weeks later 1
Complete Recovery Is Said To Have Occured As Follows: Five days from beginning of disease 1 Ten days from beginning of disease 1 Two weeks days from beginning of disease 3 Six days from beginning of disease 1 Three Months from beginning of disease 1
Distribution Of Paralysis One leg 15 Both legs 7 One Arm 8 One arm and one leg 11 One arm and both legs 5 Both arms and one leg 1 Four extremities 6 Not stated 14 Total 67 Mortality. -- Four cases terminated fatally, 2 dying of respiratory paralysis and 2 of exhaustion, stupor and convulsions. Conclusions The conclusions which would seem warranted by the investigation of 1908 are as follows: That the disease was less prevalent in the state than in 1907, as was also cerebrospinal meningitis. That the distribution of cases was unlike that of 1907, localities affected seriously in 1907 largely escaping in 1908. That this is quite the opposite of the almost identical distribution of cerebrospinal meningitis in the same two years. That half of the cases occurring in the state were comprised in an epidemic in Franklin County. Finally it may be stated that it is not to be expected that any material light will be thrown on the etiology of the disease by its observation during any one year, but it is hoped that by a study of the disease for a period of years in the same territory, conclusions of value may be established. It is also to be hoped that by the study of the stools of fresh cases some light may be thrown on the etiology.
References 1) Zeitschrift für Immunitatsforschung und experimentelle Therapie, 1909, Bd. II, heft 4, teil 1. 2) Wickman: Beitr. z. Kenntniss der Heine-Medinischen krankh. Beri., 1907. 3) N. Y. Med. Rec.. Dec. 1, 1894. 4) Boston Med And Surg. Jour., 1895, III, p. 14. 5) Lancet, 1908, vol. 1, 484. 6) Wiley and Darden: Jour. Am. Med. Asso., Feb. 20, 1909. p. 617. 7) Iowa Health Bull., November, 1908, xxii, no. 5. 8) Informal communication from Wisconsin State Board of Health. 9) Free: Jour. Nerv. and Ment. Dis., April, 1908, p. 259. 10) Sinkler: Ibid., p. 260. 11) Arch. of Diagnosis, January, 1908. p. 31. 12) Arch. of Pediatrics, January, 1908, p. 36. 13) Jour. Mich. State Med. Soc., April. 1909. 14) Ibid, February, 1908. 15) Wickman: Studien Ober Poliom. Acuta, Berlin, 1905. 16) Albany Med. Jour., 1908, xxix, p. 799. 17) H. W. Berg N. Y. Med. Rec., 1908. lxxiii, p. 1; Joseph Collins: Ibid 1907 lxxii, p. 725; Terriberry: Ibid. 1907, lxxii, p. 920; Jennings: Med. Rev. of Reviews, May, 1908. p. 197; Collins and Romeiser: Jour. Am. Med. Asso., May 30. 1908. p. 1766; Starr: Ibid., July 11. 1908, p. 112 (with list of epidemics); V.P. Gibney and C. Wallace: Ibid., Dec. 21, 1907, p. 2082. 18) Wien. med -Wochenschr., 1908, xlvii, p. 2563. 19) H. D. Stephen: Intencol. Med. Jour, of Australasia, November, 1908; Abst. Lancet, April 3, 1909, p. 999. 20) Scot. Med and Sung. Jour., June, 1908, p.50l. 21) Edler and Huntoon: Jour, of Med. Research, June, 1909.
From Boston Medical And Surgical Journal (7/22/1909) p115:
An Epidemic Of Infantile Paralysis In
Western Massachusetts In 1908By Herbert C. Emerson, M.D., Springfield, Mass.
State Inspector Of Health
District 14
TEXT HARpub Commentary Note. -- The details of this investigation will appear later in a publication of the Massachusetts State Board of Health. The following investigation of this epidemic here published in abstract was made at the sugggestion of Dr. Henry P. Walcott, chairman of the State Board of Health. The information was obtained through the courtesy and assistance of the physicians which enabled the writer to visit the homes of all the cases reported in this epidemic. The writer spent a month living in the towns in which the epidemic occurred and made several subsequent visits to these places. Geographical Distribution Sixty-nine cases of infantile paralysis, or approximately one half the total number reported in the state during 1908, occurred in western Massachusetts and were distributed as follows:
Colrain 24 Erving 2 Buckland 9 Adams 1 Shelburne Falls 8 Cheshire 1 Montague 7 Deerfield 1 Bernardston 5 Gill 1 Greenfield 4 North Adams 1 Heath 4 West Hawley 1 [Map Of Franklin County, tasked] With the exception of three isolated cases in Adams, North Adams and Cheshire, the cases occurred in a sparcely-settled portion of the state in the larger towns (Shelburne Falls, Buckland) on the Deerfield River, and its main feeder, the North River (Colrain), and at that point on the Connecticut (Turners Falls) where the Millers and Falls rivers empty into it. As both the valleys of the Deerfield and North rivers are very narrow, the bulk of the population lives naturally very near these streams. Twenty-four cases occurred in Colrain (population 1,800), a town of five villages containing three cotton mills in the narrow North River valley. Nine of these cases occurred in Griswoldvile (population 350), the largest of the three mill villages. Thirteen cases occurred in the village af Shelburne Falls, a manufacturing town with a population of 2,500, which includes the villages of Shelburne Falls and Buckland which are separated by the Deerfield River only. Six cases occurred in Turners Falls, a large manufacturing town on the Connecticut River, and two cases were other towns across the river. Fifty-two of the 66 cases were located in the valley on these streams, while 10 of the remainder were hill cases in country districts adjacent to these towns. There were 3 scattered cases in Greenfield. The actual distance from the houses where the cases occurred to these streams above mentioned, including mill ponds, canals, etc., was found to be as follows: Four cases were one quarter of a mile distant, 15 cases were one eighth of a mile distant, 33 cases were less than 500 ft. distant, of which 20 cases were from 10 to 200 ft. distant. Most cases were in valleys near the streams. The relation of the hill cases to those in the valley was noted, and in every case it was found that the hill cases gave a history of visiting, driving or in some way spending time in the nearby towns which were upon the streams as above mentioned. It may be stated that there was no case in the 66 under consideration which had not been exposed recently to the valley influences, if any. Every hill case visited areas near waterways. In addition to the above 69 cases in western Massachusetts, 6 cases of infantile paralysis occurred in southern Vermont in territory, contiguous to the Colrain-Heath district. They all appeared to be independent cases and 4 of them were located near the Deerfleld River or its branches. [A map of the upriver area in Vermont, and nearby industry, is tasked.] Sequence Of Cases Sixty-five of the cases occurred in the summer months as follows: June, 6; July, 28; August, 26; September, 5; while isolated cases occurred in March 1, April 1 and in November 2. The height of the outbreak appears to have been July 25 on which date 6 cases occurred in four towns as follows: Bernardston 2 (one family), Buckland 2, Shelburne Falls 1, Colrain 1. The early cases occurred at various points throughout the district concerned as follows: In Turners Falls district June 4 (the earliest case), in the Shelburne Falls district June 20, in the Colrain district July 1 in the southern part of this territory, and July 4 in the northerly part of this section. The outbreak in the various towns, with the exception of a few small groups, was not an explosive one, but cases occurred from time to time, covering a period of from six to eight weeks in each town. Contact And Relation Of Cases To Each Other Turners Falls Village and suburbs. -- The first case occurred in Turners Falls village on June 4, and from this time on to July 20 there were 7 additional cases in this district. There was 1 case of known contact and 2 of possible contact. Greenfield-Deerfield.-- Four independent cases occurred in these towns from July 9 to Sept. 8. Bernardston. -- There were 3 cases practically coincident in one family July 25 and 2 cases in another family, the second being sick three weeks after the first. Shelburne Falls. -- The first case in this group occurred June 20 on a mountain farm and the second case developed in this family one week later. There were 6 other cases in this group during July and August, 2 being coincident in one family, and 1 contact - case having frequently visited one of the cases. Buckland. -- There were 2 cases practically coincident in one family and one contact case who had visited, a neighbor’s sick child. There were 5 additional cases in this town during July and August. Colrain. -- Three cases occurred in the village of Frankton and had their first symptoms July 7, 16 and 25. The houses were 75 ft. apart and there was more or less commingling of all the children. Six cases occurred in the village of Shattuckville, 2 of which were coincident in one family on July 16 and 17, and 2 were coincident in another family on Aug. 3. There were 9 cases in the village of Griswoldville during July and August, 8 of which were independent and 1 a contact case who had been sleeping and taking care of her younger sister. At Willis Place there were 3 independent cases in a large tenement block. HARpub postulates Colrain as the main upstream source of polio-producing pollutants. Here were the greatest density, the greatest number of victims, and 3 cotton mills poised on the edge of the river which flows down through the other areas with lesser densities of cases. Carbon tetrachloride, used in cottonseed oil extraction at this time had just gone into unprecedented high volume production in the U.S. (not mentioned in the article). The 54 cases just reviewed constitute what may be called the group cases, of which 43 are independent and 11 are possible contact cases, 7 of which are of known and 4 of possible contact. The 15 remaining cases are all independent, 9 of which are connected by location with the groups above mentioned and 6 are isolated.
Independent Cases Group 43 Connected With The Group 9 Isolated 6 SubTotal 58 Contact Cases Known 7 Possible 4 SubTotal 11 Total 69 Time Interval The time interval elapsing between the exposure and onset of symptoms of the 7 cases of known contact is as follows: Three cases of intimate contact with intervals of 24 days, 14 days and 8 days; 4 cases of contact not intimate, 14 days, 9 days (two instances) and 7 days. Out of the whole number of cases there were but 2 that were isolated during their illness. One was in a family in which there were no other children and 1 was in a house in which there were 3 children, and this case was as thoroughly isolated as if it were a case of scarlet fever. The remaining 67 cases were not isolated in any degree except that in a few instances the serious illness of the child was a sufficient bar to any intimate contact with the other children in the family. Careful inquiry into the conditions that obtained during the illness of the 67 in which there was no isolation shows that there were 166 children in these families, 4 of which later had the disease; that there were 4 instances in which the sick child slept with a brother or sister up to the time of illness, 7 during the first few days of illness and 5 throughout the entire illness; that there were 9 instances in which the other children of the family drank from the same cup; that there were 12 instances in which the children in the family and neighbors children kissed the sick child during the acute illness. It is impossible to determine the number of times that contact of the kind just mentioned occurred, but the above detail indicates to how great an extent the intimacy of the well with the sick did occur. Out of the entire number involved to the intimate contact just described, 2 cases developed the disease. Investigation further showed that there were, in addition to the 166 exposed children in the families, 86 children among neighbors and friends (making a total of 244 children) who were in intimate contact with the 67 cases. By intimate contact is meant (and this appeared to be almost universal) as free intercourse of the well and the sick as the patient’s condition would permit. Playing with the child, sitting beside him, taking naps lying on the lounge or bed with him were the conditions that existed in almost every case. The total number of children that were more or less intimately exposed to the 67 cases is probably at least twice or three times the number of known exposures. Weather A study of the plotted curves of temperature, rainfall (secured from the report of the Hatch Experiment Station at Amherst) and incidence of cases appears to show no correlation whatever. Diet Investigation of the diet showed the following: General diet 58, cow’s milk exclusively 4, breast milk and cow’s milk 3, breast milk and fruit, etc., 4. Milk was found to be used in considerable quantities by 29 cases, in small amounts by 26, while 3 cases used no milk at all. Nineteen families produced their own milk and there were 22 milkmen serving 36 families, while the milk for the remainder of the cases was bought from various sources. None of the infants under one year of age were fed upon breast milk alone.
Diet Of Victims (HARpub) General diet 58 Cow's milk, exclusively 4 Breast milk, and cow's milk 3 Breast milk, and fruit, etc. 4 Milk, considerable quantities 29 Milk, small amounts 26 No milk 3 Milk, family produced 19 Milkmen, serving 36 families 22 Breast milk fed infants <1 Year 0 62 of the 69 cases were drinking cow's milk. Yet, no breastfed infant under 1 year acquired infantile paralysis. Breastmilk would have less pesticide than polluted cows's milk, water, or produce. Cow's milk and water are prime suspects for HARpub, in terms of toxicology. Cows could go to the streams and guzzle large quantities of polluted water, concentrating organochlorines in milk fat. Unusual Diet It was not found possible to get a more detailed history of the diet than is given above, except that in 6 cases it was especially mentioned that fruit and berries had been a very large item of diet. In the 2 infants, five and eight months old, bananas and berries were given as the diet in addition to breast milk. In 1 case the illness was attributed to eating heartily of English mulberries and in 3 cases to the eating of large amounts of blackberries and blueberries. In 39 instances it. was stated that food supplies were bought from peddlers, and it was found that these carts frequently served the town and country districts in their localities. Preceding Illness Practically all the cases had been in good health previous to this attack. One child was in very feeble health, 5 were in a more or less run-down condition and 63 were in their usual condition or good health. (One had recovered two months before from a slight attack of scarlet fever.) Condition Immediately Preceding Onset
Traumatism. -- There were 3 cases of traumatism as follows: Fall from bicycle three weeks before illness. Fall from piazza four weeks before illness. Burn of arm and chest three weeks before illness. There were no special symptoms subsequent to the two falls, and the burn was healing properly when infantile paralysis developed. Over-heating. -- Five cases gave a history of possible over-heating within a day or two of the onset of the disease. Fatigue. -- Four cases were noted as suffering from marked fatigue within a day or two of this illness. One was a child of seven who had been carrying bricks up a ladder the day before he was taken ill, another was a young man of eighteen who was a noted athlete, a third had been lifting very heavy weights and a fourth was tired out with school work. Swimming. -- Five cases had been in swimming in the streams nearby and 6 cases, among children, had been playing in the brooks, ponds, etc. One child had a severe cold just before the symptoms of this disease appeared. It was noted in 1 case in a young man nineteen years old that he had been extremely nervous and very much worried for fear he would develop this disease, as he had recently attended a funeral of a classmate who died from infantile paralysis. Abortive Cases1 There were 6 cases reported which, on investigation, were found to have the same acute symptoms as the other cases, but to a less degree, and no paralysis occurred. The history of these cases seemed to eliminate the possibility of their being simple gastro-intestinal disturbances; and while the diagnosis of infantile paralysis cannot be proven, the history of the cases seemed to warrant their being considered as abortive cases of this disease. One case occurred in a family more than three weeks after the onset of a rather severe case in another brother. One case was coincident (doubtful history) with that of an older brother, while 4 cases occurred without known exposure. Symptoms Accompanying Attack Pain, more or less marked, 62 cases; pain, little or none, 7 cases; fever, 63 cases; constipation, 47 cases; diarrhea, 2 cases; nausea and vomiting, 43 cases; retraction of head, 35 cases; retention of urine, 23 cases; incontinence of urine, 1 case; brain symptoms, 13 cases; stiffness of neck, 6 cases; stiffness of spine, 7 cases. The onset in 65 cases was sudden and in 4 cases it was delayed, extending over several days. Complicating Symptoms In one case a marked urticaria was an initial symptom; in 2 cases intense pain in the stomach was noted, also as an initial symptom; in 5 cases a complicating tonsillitis was present; in 1 case a severe nose bleed took place; an extremely offensive breath was noted once; double vision occurred once, as did also marked disturbance of speech. The early symptoms in 1 case were thought to be due to swollen glands, which had been present for a year, and in another case to a rheumatic condition. In 2 cases stumbling of the child while walking and playing was one of the first symptoms noted. Diagnosis Made In 1 case no diagnosis whatever was made; in 2 cases a diagnosis of typhoid fever was made and the following diagnoses of single cases: Digestive disturbance, heat stroke, cerebrospinal meningitis, rheumatism. "We stand between Scylla and Charybdis. In the presence of an epidemic we are likely to call everything that bears the slightest resemblance to poliomyelitis a proved or almost proved case; and in the absence of an epidemic we are almost certain to fail to recognize cases which are perfectly definite examples of the disease." (Dr. Janeway, replying to Haven Emerson. From "The Recent Epidemic of Infantile Paralysis", which Emerson read before a meeting of The Johns Hopkins Medical Society, November 6, 1916) Today we know that no symptom (silent polio), the common cold, flu, fever, gastro-enteritis, meningitis, encephalitis all can be regarded as different stages of poliomyelitis, which at any stage can be regarded as abortive, if it does not continue to the more acute stage. Recovery Excluding the 6 abortive cases, 58 cases were examined in this regard about nine months after the illness. Six cases appeared to have completely recovered from the paralysis. Six others appeared to have recovered, but of these 5 were infants and could not be satisfactorily examined, while the other was sick at the time of examination. These 6 cases were classed as apparent recovery. Forty-two cases had partially recovered from paralysis, while 4 cases had shown but very slight improvement since the attack. Deaths There were 5 fatal cases, 1 of which made a partial recovery and died two months later of bronchopneumonia. The length of the illness in days was as follows: Female eight months, sixty-five (broncho-pneurnonia); male three years, six; female four years, four; female fifteen years, five; male nineteen years, six. Age And Sex Forty-two were males and 27 were females. This epidemic was characterized by the number of cases in middle and late childhood and young adult life. It will be noticed that there were 6 cases over seventeen years of age all in males. The following table shows the age and sex of each case:
Age Male Female Total <1 2 5 7 1 1 4 5 2 5 4 9 3 7 1 8 4 5 3 8 5 0 2 2 6 2 1 3 7 5 1 6 8 2 0 2 9 1 1 2 10 1 1 2 11 0 0 0 12 1 0 1 13 1 0 1 14 2 0 2 15 0 2 2 16 0 1 1 17 0 1 1 18 1 0 1 19 2 0 2 20 1 0 1 21 1 0 1 22 1 0 1 23 0 0 0 24 0 0 0 25 1 0 1 Totals 42 27 69 School As the outbreak occurred in July and August, there were no results that could be attributed to school influences and but 3 of the children attended school. Local Conditions Investigation of the home conditions of each case shows that sanitary conditions were found to be excellent in 4 cases, good in 17, fair in 31 and bad in 17. Forty-one of the cases lived in detached houses, 17 in two-tenement and 3 in three-tenement houses, while but 8 lived in houses having four or more tenements. The elevation of the dwelling was noted as high in 28 cases, as medium in 22 and low in 19. Forty-two of the houses were considered to be dry, while 27 were noted as being in a more or less damp location. There were cellars in all of the houses, 42 of which were dry and 23 were damp, while 4 were found to be very damp or wet. The water supply was given as spring water in 53, as the town supply in 14 and from wells in but 2 cases. The sanitary arrangements in the houses showed that 23 houses had water closets connected with the sewer and 46 had earth closets; that the sink water from 30 houses was carried into the sewer and in 39 cases it was disposed of in various ways on the land nearby or in pipes to the nearest brook, pond, etc. Screens were found to be used in 65 cases and not used in but 4 cases. Inquiry into the question of flies and mosquitoes showed that flies were said to be numerous in 28 instances, few in 39 and not present in 2; that mosquitoes were said to be numerous in 22 instances, few in 45 and not present in 2. No history of insect bites at the time of illness was obtained. Summary We are dealing with groups of cases of an acute disease attacking children chiefly, but youth and adults frequently up to the age of twenty-five years, among the inhabitants of river valleys in sparsely-settled communities, occurring during the summer months of a hot, dry season. The persons attacked lived chiefly in detached houses and but eight lived in houses or blocks of more than three tenements. Although the cause of the disease is not known, it can undoubtedly be classed as infectious, as its distribution and incidence in localities are similar to those of other infectious diseases and strongly suggest a common cause. Ninety per cent of the persons attacked were in good health, and while a few instances of traumatism, over-heating, fatigue and swimming were noted previous to the onset, the history of these cases does not seem to warrant the placing of much etiological responsibility upon these occurrences. They were not different from what might be found in the history of almost any groups of persons at this season. 90% of the polio cases were healthy people (with well-functioning immune systems). With regard to the contagiousness of the disease, the investigation of this group of cases suggests that the disease is but mildly contagious to say the most. A large number of children were in intimate ontact with those that were sick, and of these children an insignificant minority developed the disease. Although the group of cases investigated is a small one from which to draw generalizations, it must be remembered that the circumstances were particularly favorable to the investigation of points of contact between sick and well and of the detection of contagion. The sanitary conditions under which most of the cases lived were not good. Dampness prevailed in many locations. Most of the houses were very near water, but it must be remembered that the outbreak was in the valleys. Most of the houses had no sewer connection. The marked digestive disturbances, which were early and notable symptoms, suggest the stomach as the port of entry for the infection. It does not seem possible in this outbreak to blame the varied sources of milk or water supply as a carrier of the infection, unless it be considered that the cause of the disease may be present in all milk or in all water. That the cause may be connected with the food seems possible. It is important to note that none of the seven infants under one year of age were fed exclusively upon breast milk. Stomach is portal of entry. Milk and water could be carrier only if there were a causal agent in milk and water. No victim under 1 year of age was fed exclusively on breastmilk. The only positive correlations are milk, water, and food. Breastmilk is out. The fact that all the cases living on the hill farms had been in the valley towns recently where infection may have occurred and that many families purchased some of their food supplies from peddlers’ carts which act as the go-between between the town and the country, may be noteworthy. It is not known what influences the dry season with its low water and the proximity of many of the houses to water contribute, but these facts appear to be significant. Slow flowing streams means higher concentrations of pollutants in the waterways. Polluted streams may seep into groundwater and thus into wells. Conclusions
From an intimate acquaintance with all the facts and conditions of this outbreak we conclude that 1) Infantile paralyis is a disease produced by some external agent; that is, it is an infectious disease. 2) That it is mildly contagious at the most. 3) That the harmful agent appears to enter the digestive tract in most instances. 4) But that until the organism causing the disease is known, it would be impossible to say whether the infection is carried directly to the patient or by means of food. Herein it is admitted that the causal "organism" is unknown and that the disease shows little evidence of contagion. This patternless appearance of cases is the description of mass poisoning, however, with bias, the language of germ theory is strictly used, and there is a total abscence of toxicological considerations. The message is: Toxic cause for polio is unthinkable.
It inconceivable that the health inspector would even think to continue his investigation of the victims and their circumstances with a toxicological investigation, tracking the etiology of this epidemic, searching for the upstream source, interviewing and investigating the various industries that were upstream, asking workers and owners what and when they are dumping into the streams and rivers.
Factories are regularly situated by waterways for the purpose of being able to dump waste products, and for transportation. Living downstream is a risk. There was ample reason to perform a toxicological investigation -- high-volume carbon-tetrachloride production began in the U.S. in 1907. In 1908 carbon-tetrachloride was used as a fumigant in grain silos, etc. It was also used to extract cotton seed oil, probably in the Colrain cotton mills, which was at the geographic center of the epidemic, where the highest density of poio cases occurred, in this 1908 Massachusetts polio epidemic in Franklin County.Dr. Scobey comments on this epidemic (see Endogenous Virus? and )
Footnotes: 1) This type of the disease is recognized and described by Wickman.
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