A MONOGRAPH = ON —/— The Epidemic of Poliomyelitis (Infantile Paralysis) IN NEW YORK CITY IN 1916 Based on the Official Reports of the Bureaus of the Department of Health PUBLISHED UNDER THE DIRECTION OF THE DEPARTMENT OF HEALTH OF NEW YORK CITY 1917 =) em } a CASES BY ONSETomuun ~ REPORTED CASES wee Jepnn DEATHS mm 28's 8 %¥ 3 2 3 2 8 BOARD OF HEALTH. Haven Emerson, M. D., Commissioner of Health and President of the Board. « ARTHUR WoODS, Police Commissioner. L. E. Corer, M. D,, Health Officer Port of New York. FEMA dant Saal LE Wheto a ov al 1 TABLE OF CONTENTS. PAGE IErOQUEEION ios a ei vs ai nds on tn main iaiais uaa sin bide leu to tury fnloio ofols 9 Chapter 1, Historical. . Ji cui ovs ios sal vunivs pininilniinal ss siosiisls 11 Chapter IT, FHology o.oo iis ohn vin salsa dali iets leioioto lols ft io2ne 82 Chapter 111, Epidemiology «ss «iva viiwwnmvnmniiane sisaissi oth poping 93 Chapter IV, Epidemiology, continued... ... ...... cones nic nobis 102 Chapter V, Insects as Carriers of Infection. .....c. LL woh hg 136 Chapter VI, Poliomyelitis in New York State in 1916............... 179 Chapter VIE, Pathology ..ov.... ino ovnsnos os sannssiunsinssnssebin 188 Chapter VIII, Symptomatology ..........cccoiuvvreiiannriaenssne 196 Chapter IX, Diagnosis and Differential Diagnosis.................. 201 Chapter X, Prognosis ........ 00s vrivs svsisaiinms siininn a vis diss idies 241 Chapter XI, Record of Treatment Employed...................... 244 Chapter X11, A Discussion of Treatment... 1.0. bbe 0h 264 Chapter XIII, Prophylaxis uuu riiarsrnansinsansn, in 290 APPEAR Loh hl rie ds edi vn el le ee states nies a iate 293 FINE INTRODUCTION. To: His Honor the Mayor, The Board of Estimate and Apportionment, The People of New York City. This report of the poliomyelitis epidemic is submitted as the record of an event of importance to the science of medicine and touching closely the life and happiness of individuals of this community. Our present ignorance of such facts as will permit of a control of this epidemic disease imposes a special duty to record all data which may con- ceivably be of value or prove of service in the further study and solution of the many questions which must be answered before we can give assurance that a repetition of a similar epidemic can be prevented. The data are presented so far as our present understanding permits in a way to render possible the widest use of the observations of the officers of the Department of Health by those engaged in the study, teaching and practice of preventive medicine. It is exjected that the intelligent lay reader, as well as the large group of professional workers in medicine and associated sciences will find herein a fund of interesting information which may prepare them to appreciate more clearly the possibilities and limitations under which the officers of Federal, State or Municipal health organizations must apply the accepted facts of science in the administration of the public health laws on behalf of the community. Beginning with an historical sketch of the disease and proceeding with the record of the epidemic in this City, with a reference to the extent of its spread elsewhere in the United States, the report will deal with every phase of the disease as seen by the Department of Health, in co-operation with other Departments of City, State and Federal Government, and with many official and unofficial advisory groups and organizations. No such report can be the production of one mind, and I wish here and now to express with all sincerity my respect and admiration for the universal co-operation of the many loyal public servants in the Department of Health who have made this publication possible. At this time and place, it is peculiarly fitting to express and record the appreciation felt by the Board of Health for the admirable skill and spirit shown by the officers of the United States Public Health Service, who were assigned to undertake epidemiological studies of the disease in 10 and about New York City, and to assist in such phases of the administrative supervision of the disease as affected interstate quarantine. The Department of Health of the City received many benefits from the cordial and effective co-operation which the State Department of Health took pains to offer and exhibit on all suitable occasions, and there were instances where the officers of the City were able to reciprocate in kind for the benefit of v citizens of State and City, whose interests would often have been jeopardized if there had been anything less than sympathetic action by the respective departme . Respect ubmitted by . Haven Emerson, M. D,, Commissioner of Health, - — ss? CHAPTER I. ’ Historical. Poliomyelitis has been recorded in the United States as among the rarer diseases of the central nervous system since it was first described by Heine in 1840. In 1874 it was a disease offs rare occurrence or so seldom recognized as a distinct clinical entity, e leading consulting physicians of the largest cities in this country and abroad had not, in their whole pro- fessional careers, seen more than a handful of cases. The knowledge of the pathology of the disease at that time was based on a smaller number of autopsies recorded in the whole medical literature than were performed at one of the Department hospitals during the past summer. The average number of deaths from poliomyelitis in any one of ten weeks during July, August and September, 1916, exceeded the deaths from this disease reported in the past five years in New York City. In fact, the deaths from this disease were of such rare occurrence up to the year 1912, except during the epidemic of 1907, that they were not even separated from the general group of “other diseases of the nervous system.” In the years 1912-1915 there were respectively 70, 54, 34 and 13 deaths from the disease and in 1916 up to June 1, there were only 6 deaths, while the average weekly number of deaths from july 1 to September 9, 1916, was 209. he Since the early years of this century there has been an increasing general gE of distribution in this country and a growing incidence of the disease. Over 5,000 deaths from poliomyelitis are recorded by the United States y Census Bureau, as having occurred in the registration area* in the quin- ~ quenium 1910 to 1914. A conservative estimate would place the probable number of cases during these five years in this area as 30,000. Over 27,000 cases and 6,000 deaths from poliomyelitis occurred in the registration area from June to November, 1916. During the past summer there were other distinct foci of infection evidently independent in their origin and not, so far as could be learned, traceable to each other or to the City of New York. These were roughly the State of Minnesota and the South Atlantic States, each of which areas was responsible for a con- siderable number of cases pretty widely distributed. Although foci of infection in many localities in the States adjacent to New York City and State, closely bound to it by social, business and trans- portation connections, apparently had their own local origins, the great majority of cases in the metropolitan area extending into New Jersey, Con- * The Registration Area of the U. S. Census embraces those states and cities whose vital statistics are regarded as sufficiently complete and accurate to warrant tabulation by the Census Office. At the present time the area includes 26 states and 36 cities outside of these states. In 1916 this area had a population of 71,621,632. 7 w= a 12 necticut, Massachusetts and New York State should be considered as units in the New York City epidemic. As has been observed to be the case in epidemics elsewhere, the distribution of cases outside of New York City into the adjacent country and cities followed closely the traffic lines and the distribution of cases or carriers of the disease from this City. Thus it can be seen that, apart from the intense local interest and alarm resulting from the sudden attack of the disease in New York City in epidemic form, there is a national and even continental aspect to the recent events which justifies prompt and complete reports of all available facts, and demands the closest study and attention of the federal state and local health officers throughout the country. Since 1912, when there was a pretty even distribution of the disease throughout the year by months, with a total of 504 cases, there had been a steady decrease in its incidence until June, 1916, as can be seen from the following table : 1911. 1912. “1913. « 1914. “1913 JER drain nas ss 6 31 12 3 7 nn A SAN ht ES 5 53 5 1] 3 March. Ei ny de 3 38 6 8 4 LL SS RA OE RN i 3 23 7 7 4 Lh a EOE CELE CI 3 14 11 2 4 IIE Ei rr ed hi rns a mds 3 40 7 7 7 LL RC I Ee SN 21 42 38 4 4 IOUS, ees cece Bee vain ares aa ea 27 40 44 21 11 September... ir as ie 58 61 95 26 11 Otober Lh die sara A 89 75 48 18 26 Nokember i... iii csi 67 65 2 6 16 DecemBer i. nie nr bn ain vie il 73 22 4 6 3 otal... en adic in 358 504 300 129 100 The reporting of the disease by physicians was not required in New York until November, 1910, and estimates of its previous prevalence based on deaths are unreliable, owing to wide variations in the reported death rate in different epidemics. Moreover, there is reason to believe that the num- ber of reported cases shown in the above table is considerably below the number which actually occurred. This is borne out, for example, by obser- vations made at some of the larger dispensaries, of the number of old para- lytic cases applying for treatment. In the first five months of 1916, only 17 cases of the disease were reported, of which 8 were in Manhattan, 4 in The Bronx, 5 in Brooklyn and none in Queens or Richmond. EripEMIC OF 1916. To judge by the reports of physicians up to June lst, there was nothing - to excite suspicion that we were already at the onset of an epidemic. Within the first eight days of June, 6 cases were reported from Brooklyn, 13 from which borough no cases had been reported up to this time in 1916 and none in June from the other boroughs. The six cases were reported as follows: Date Reported. Name. Age. Address. June 6th. John Pamaris.... vee 10 months ....... 53 Garfield place. June 6th. Armanda Schuccjio .... 2 years 8 months 5014 Seventh avenue. June 8th. William Cortell ........ 8 years i. .vaevens 630 Forty-fifth street. June 8th. John Lessa .....:...eq. 20 months: ...uis +s 282 First street. Jane Sth.” Tony Piclo i..ccvneciss 1lyedes,......... 251 Third avenue. June 8th. Mitchell Alvin ......... 117 iyears........ 78 Utica avenue. Only five cases in the entire city had been reported to the Department of Health in May, and yet when we assign the cases, which were reported at later dates (discovered by the house to house visits of doctors and nurses of the Department in the section of Brooklyn first invaded, a thickly populated Italian section, bounded by Fourth avenue, Nevins, Carroll and ‘Union streets), to the date when the first symptoms of sickness were ob- served, i. e., to the date of onset of the disease in each case, we find that in the month of May, 29 cases of poliomyelitis had their origin and were doubtless capable of spreading the disease to or through those with whom they came in contact. It must be remembered that none of these 29 cases, in which the onset occurred before June 6th were known to the officers of the Health Depart- ment, until the house to house search, after June 6th disclosed their where- abouts, and it was only the report of the 6 cases from Brooklyn, 2 on June 6th and 4 on June 8th, which served as a warning of an impending epidemic. Further, it is well to bear in mind that although at the beginning, and throughout the epidemic, Brooklyn supplied the largest number of cases, the unreported cases which had their onset before June 6th were distributed throughout the five boroughs: in May in Manhattan. on June 2d in The Bronx. in May in Brooklyn. in May in Queens. in May in Richmond. nN — NW On June 8th, when the homes of the 6 reported cases were found to be in a fairly circumscribed area, and when a notice was received from the research force of the Department laboratory that an unusual number of requests had, within the past few days been received, for positive diagnosis in cases of suspected poliomyelitis, orders were given to make an immediate and special investigation, by inquiry of physicians practicing in the area affected, and by instituting a house to house canvass for unreported and unrecognized cases. That there was not an earlier recognition of the approaching epidemic and a study of the disease from the epidemiological 14 * standpoint, was due solely to the fact that none of the cases which occurred in May and before the 6th of June were reported to the Department of Health. It is not to be inferred that this failure was due wholly to the not uncommon delay in reporting cases of notifiable disease by practicing physicians, but is to be attributed largely to the fact that this disease is not always sufficiently severe in its early symptoms to demand immediate medical attention, according to the idea of many parents, and further to the equally important fact that only a complete physical examination with special attention to the response of various tests of muscular reflexes will elicit the evidences of paralysis in many of the mild cases. Only a thoroughly alert public and a forewarned profession could have prevented the delay in official knowledge of the threatening epidemic. That energetic measures were taken as soon as six verified cases of the disease were reported on June 6th and 8th, is a sufficient reply to any lingering suspicions that the Department of Health awaited the actual presence of a calamity before taking measures of protection. On June 15th, in addition to a number of cases discovered by visits of medical inspectors and nurses throughout the now obviously infected area of Brooklyn, several cases of recent paralysis were noted among the infants attending the Baby Health Station at 184 Fourth avenue, Brooklyn. The mothers of these children, all unaware of the existence of the disease or its communicable character, brought their babies to the doctors, com- plaining that the child could not hold the bottle or that the leg seemed limp for the past few days, and there had been a little loss of appetite and some restlessness. OrrFiciAL Notice oF UNUSUAL PREVALENCE OF ACUTE POLIOMYELITIS IN e EripEmMIic Form. The first official announcement of the existence of an unusual num- ber of cases of poliomyelitis in New York City (in the Borough of Brook- lyn) was made in a press bulletin issued Saturday, June 17th, and published in the newspapers on the following day. As in the case of all the press bulletins issued by the Department of Health, multigraphied copies of this bulletin were sent to all the newspapers in the City, to the medical journals and to all the important news bureaus. This first bulletin called attention to the value of spinal fluid examinations in the diagnosis of poliomyelitis and announced that lumbar puncture and the laboratory examination of spinal fluid would be made free of charge by the Department of Health. At the same time a letter was sent to all the physicians in Brooklyn, calling attention to the existence of a group of cases of poliomyelitis in their borough, and asking for their co-operation in controlling the disease. Owing to the interest manifested by the newspapers in the epidemic, and in order to make certain that information emanating from the Depart- 15 - ment of Health should be accurate, a daily press bulletin service was inaugurated. At a little later date (June 30th), the Surgeon General of the United States Public Health Service was notified that an epidemic was under way, and the facts upon which this belief was based were given in full. The New York State Department of Health and the health officers of neighbor- ing States, and of a few of the larger nearby communities were notified at the same time. EMERGENCY FIELD FORCE ASSIGNED. On June 20th, seven additional nurses, and on June 22nd a supple- mentary corps of medical inspectors were assigned, the nurses to search for unreported and unrecognized cases by an extension of the house-to-house visits, and the medical inspectors to visit the numerous cases now reported, to confirm the diagnosis made by the family physician and to examine suspects reported through many non-professional channels. The American Society for the Prevention of Cruelty to Animals was requested to take immediate measures to collect all stray cats and dogs found in the infected localities. The Department of Street Cleaning began active co-operation to give a special clean-up in South Brooklyn and to discontinue the use of burlap bags in the daily collection of rubbish. On June 23rd, there were reported 48 cases, about half among Italian families, as compared with a total of 63 reported up to this date. Many of these were of considerable duration, their onsets having occurred even in the month of May, and almost all of them had either escaped recognition as poliomyelitis by the private physician or had not been under medical care. A further evidence that many cases had escaped detection for some weeks, and had been exposing others to infection for a considerable period, was presented by a leading orthopaedic surgeon in Brooklyn, to whose dispensary class cases applied with already well developed deformities, fol- lowing the acute onset of paralysis. On June 24th, in order to give immediate reply to many anxious inquiries and suggestions as to the part played by schools in the spread of the disease, a press bulletin was issued, pointing out the facts that 90 per cent. of the cases were in children under school age, that the cases were not limited to any one school district or to children of the same classroom. The school term ended on June 30th. At the same time there was issued a special bulletin for parents, emphasizing the known facts which would be of service in preventing the spread of the disease in homes. The presence of the virus in the discharges from nose and throat, and bowels of infected individuals, the probability that atypical and non-paralytic cases were as dangerous and as numerous as the paralytic cases, and that little value or protection could be expected from the use of so-called antiseptic gargles and nose-sprays, were explained. = iy q 16 Co-OPERATION OF NEWSPAPERS. The advantages to be expected from intelligent and alert self-interest, and the rapidly increasing number of cases reported day by day, determined the Department to take the unusual step of publishing in the daily press the names and addresses of all true cases reported in the previous twenty-four hours. This decision was made after conference with the Corporation Counsel's office and with the managing editors of some of the prominent newspapers. The first list was printed on June 28th, and this practice was followed daily thereafter until September 9th, after which date the Sunday list was omitted each week. On October 17th a weekly list was substituted, and on November 6th further press publication of names and addresses was discontinued, and thereafter the reported cases of polio- myelitis were printed only on the daily list as issued for many years past to all schools, child caring institutions, etc. From the beginning, the interest and co-operation of foreign-language newspapers were enlisted for publica- tion of daily lists, and all official press bulletins. ESTABLISHMENT OF QUARANTINE REGULATIONS. On June 28th the Board of Health met and passed resolutions requir- ing eight weeks’ isolation instead of six weeks, and demanding immediate hospitalization of all patients for whom the following requirements could not be met: (a) Daily attendance of a physician. (b) Special attendant who must observe quarantine regulations, do no cooking, and avoid contact with other children of the house- hold. (c) Special room for patient and attendant. (d) Screening of windows of patient’s room. (e) Separate toilet for the family. (f) Exclusion of food handlers from work. (g) Disinfection of bed linen of the patient and renovation of room occupied, after removal of patient. The rapid accumulation of patients at Kingston Avenue Hospital, to which all Brooklyn cases were taken, made it necessary to transfer con- valescents to other hospitals of the Department, and later to the many private hospitals which offered their facilities to the City. This procedure of sending all cases for immediate admission to a hospital in the borough of residence was carried out, with but rare exception, throughout the epidemic, the opening of the new contagious disease hospital of the Depart- ment of Health, the Queensboro Hospital at Jamaica, on June 29th, and the offer of the Swinburne Island Hospital and medical and nursing staff to the City by the Health Officer of the Port, providing Queens and Richmond with excellent local isolation facilities, the Boroughs of Manhattan and The Bronx being served by Willard Parker and Riverside Hospitals respec- 7 tively. Patrolmen of the Sanitary Squad were assigned to visit quarantined premises every other day and enforce the regulations. On June 29th the Queensboro Hospital was opened, thus giving imme- diate relief to the Kingston Avenue Hospital, already crowded. By using the screened porches and obtaining accommodations for nurses in a neigh- boring house rented for this purpose, it was found possible to accommodate as many as 112 children at a time, though the normal capacity of the hospital is 80 patients. Apvisory COMMITTEE ON POLIOMYELITIS. On June 30th, there met for the first of its nine sessions, an Advisory Committee to the Department of Health. To this Committee were sub- mitted all the important matters in relation to the administrative and pro- fessional work of the Department of Health in the epidemic, concerning which professional opinion was divided, or at least not yet positively de- clared. Two members of the Committee on Poliomyelitis of the New York Neurological and the Pediatric Section of the New York Academy of Medicine, which studied the epidemic of 1907, and prominent consultants in three special branches of medicine, namely pediatrics, orthopaedics, and neurology, served on this Committee throughout the summer, and all the decisions reached, or new policies introduced by the Department of Health were submitted to this Committee for discussion and vote. Furthermore, through this Committee, the Department was able to keep in touch with the needs and difficulties of the medical profession and to meet as promptly as possible all reasonable complaints, for it must be evident to the lay reader that the administrative regulation of the disease implied not only inter- ference with the personal liberty of the members of many households, but a sacrifice of important professional opportunities and income by the physi- cians to the poor, whose poliomyelitis patients were removed from insuf- ficiently equipped homes to the hospitals. Immediately after the meeting for organization of the Committee, at which the hospitalization and quarantine period already adopted by the Department of Health was endorsed, two leaflets of information were issued, one for laymen and one for physicians, and posters and leaflets in Italian and Yiddish were prepared. The Committee advised the placard- ing of premises for poliomyelitis, a practice previously confined to smallpox, scarlet fever, diphtheria and measles. INCREASE IN FIELD ForRCE—EDUCATIONAL CAMPAIGN STARTED. On July 1st, ten additional inspectors (physicians) and ten more nurses were assigned to the special corps of field agents to discover cases and main- tain the observance of home quarantine regulations. On this date also was held the first lecture on poliomyelitis for the benefit of the practicing physi- cians of Brooklyn. Dr. Simon Flexner assisted the representative of the 18 Department of Health in presenting to the physicians assembled at the Polhemus Clinic of the Long Island College Hospital the important facts bearing upon the diagnosis, transmission and prevention of the disease. Addresses and lectures, and lecture-clinics were given all through the epidemic, those which were of special importance being the great meeting of the New York Academy of Medicine on July 13th, when the Aeolian Hall was filled to its capacity to listen to a symposium upon various phases of the disease, and the system of clinics at hospitals inaugurated on July 24th. SpreciAL PoriomyeLiTis CLINICS. Inasmuch as prompt diagnosis by the attending physicians is of para- mount importance in the administrative control of infectious diseases, and because it was realized that many of the physicians in this city probably had not had the opportunity to observe any considerable number of cases of poliomyelitis in the past, the Department of Health decided to organize a series of bedside clinics open to practicing physicians in this city. Through the co-operation of the attending physicians, special poliomyelitis clinics were arranged for at the following hospitals, the clinics to be held during the week commencing July 24th: Babies’ Hospital, Bellevue Hospital, Kingston Avenue Hospital, Mt. Sinai Hospital, Swinburne Island (Quarantine Station), Willard Parker Hospital. Multigraphed announcements regarding these clinics were sent by mail to every physician in the city, and a notice was also published in the Weekly Bulletin. The clinics were so well attended and so many requests were received for more clinics that an additional course was arranged for, beginning August 14th. Held at the following hospitals, these clinics con- tinued until about October 1. Babies’ Hospital, every Thursday at 4 P. M. Bellevue Hospital, Ward 32 (Contagious), every Monday at 4 PAL Kingston Avenue Hospital, every Friday at 4 P. M. Lebanon Hospital, every Tuesday at 3:30 P. M. Mt. Sinai Hospital, every Friday at 4 P. M. Willard Parker Hospital, every Wednesday at 4 P. M. In order that the clinics would give the physicians attending the same a fairly complete summary of the known facts regarding poliomyelitis, the following outline on the points to be covered was sent to each physician holding a clinic: 19 NOTES ON POINTS TO BE COVERED IN A LECTURE-CLINIC ON POLIOMYELITIS. The Disease in General. 1. Nature of the Disease (emphasize general systematic intoxica- tion). 2. Where virus is found (mucous membrane of nose, throat, in- testines, central nervous system, lymph nodes). 3. How virus is spread (nose and throat—intestinal) personal contact. 4. Epidemiology (emphasize importance of non-paralyzed cases and normal “ carriers ”’). The Case or Cases in Particular; to be demonstrated. 1. History of case. 2. General systematic intoxication. a. Psychic state: (1) Stuporous. (2) Hyperexcitable. (3) Alert and apprehensive. b. Physical signs: (1) Fever, pulse and respiration increased. (2) Lymphadenopathy. (3) Tenderness. 3. Central Nervous System: 2.c Reflexes. b. Detection of weak muscle groups. ¢. Ataxia and equilibrium disturbances. d. Spinal region pain sign. Protective Opisthotonos: (1) Neck. (2) Kernig. 4. Laboratory Aids: a. Blood count. b. Spinal fluid. c. Autopsies. d. Animal inoculation. 5. Treatment: a. General Management: (1) Rest. (2) Diet. (3) Pain control. b. Nursing: (1) Gaining confidence. (2) Careful manipulation. (3) Asepsis. €.. Special Procedures: (1) Immune serum in injection. (2) Adrenalin. (3) Artificial respiration, etc. (4) Massage and passive motion. (5) Splinting, etc. v 20 The City and the medical profession owe a special debt to the volunteers who, amid the anxious hours overfilled with hospital duties and private practice, afforded the necessary time and thought to offer to their fellow practitioners admirable clinical instruction, under the most auspicious condi- tions, for direct application among the children of the City. ADDITIONAL PRIVATE AMBULANCES ASSIGNED TO THE SERVICE OF THE CITY. On July 2nd it was found that the Department ambulances were insuffi- cient to remove all cases of isolation hospitals as rapidly as they were re- ported and the diagnosis was confirmed. Delays of serious nature occurred and as promptness of separation of the sick from the susceptible was the essence of the plan now in operation, the Ambulance Board was requested to loan additional ambulances, which they did. Throughout the epidemic the Department of Health had at its service besides its own nine ambulances, those loaned by twenty-three other hospitals, and made available for periods of one to twenty-four days at a time. This generous and timely aid was of a kind with many other similar instances of public spirit shown by the hospitals of the City throughout the summer. In addition to this a prominent automobile concern donated the services of a special motor ambulance throughout the epidemic. On this day also, the superintendents of dispensaries and institutions for children were warned to hold any suspected or recognized cases of poliomyelitis on the premises until the arrival of a Department representa- tive. By this time it was evident that, even by sacrificing some of the many important routine duties of the Health Department and devoting the entire staff of the Department to the control of the epidemic, the necessary means of coping with the situation would be lacking, and at a special meeting of the Board of Health, the following memorial was prepared, requesting the Mayor to use his powers under the Charter, to make available funds to meet the extraordinary expense of the Department: “ Whereas, The Board of Health having taken and filed among its records what it regards as sufficient proof to authorize the declara- tion of great and imminent peril to the public health by reason of impending pestilence arising from an outbreak of poliomyelitis (in- fantile paralysis) throughout the City, pursuant to section 1178 of the Greater New York Charter, the Board of Health hereby “ Resolves, That great and imminent peril exists to the public health of the people of the City of New York by reason of an out- break of poliomyelitis (infantile paralysis) throughout the City of New York; and further be it “ Resolved, That the Board of Health does hereby order that every effort be made to check and stamp out the outbreak of poliomyelitis (infantile paralysis) and does order that the same be done by and through its officers and employees and those whom it may employ for such purpose, and does hereby cause such expendi- 21 tures to be made (beyond those duly estimated for and provided), for the preservation of the public health as may be necessary and as public safety and health may demand. The expenditures aforesaid are hereby consented to. “ H ~ T AVEN EMERSON, “ Commissioner and President, Board of Health, “ FRANK A. Lorbp, “ Second Deputy Police Commissioner. “L. FE. Corrs, “ Health Officer of the Port of New York, * July 5, 1916. “On the foregoing resolution, “1, Joun Purroy Mircuer, Mayor of The City of New York, do hereby declare that imminent peril to the public health exists and approve of the foregoing expenditures. “ Jou~ Purroy MrITCHEL, : “ Mayor. “ July 5, 1916.” The report of the Auditor of the Department will give, at a glance, the character of the personal services and supplies found necessary and met from the emergency fund (page 72). PuBLIC ASSEMBLAGES RESTRICTED TO ADULTS. On July 5th all theatres and moving picture theatres were closed to children under sixteen, and on July 8th, the streets known as play blocks, provided for the sake of giving safe play space for the children in many parts of town under the auspices of the Police Department were abandoned. Street carnivals, parades, public picnics and excursions were forbidden. - These restrictions were removed from theatres, except for children under 12, on September 9th, and on September 25th restrictions of all kinds apply- ing to places of public assembly were removed. RESTRICTIONS ENFORCED IN INSTITUTIONS FOR CHILDREN. On this date also, in order to prevent the introduction of poliomyelitis into the institutions for children, the following precautions were put into effect: 1. Repeated sanitary inspections made of premises and recom- mendations offered in regard to proper cleaning of buildings. 2. All windows and doors of children’s dormitories and dining rooms were screened. 3. An effort was made to kill all flies and vermin, such as bed- bugs and roaches. 4. Garbage and refuse were immediately destroyed on the grounds. 5. The milk supply and other food used were examined at frequent intervals, and any evidence of deterioration was immediately 22 called to the attention of the persons in charge. Light, easily digested food advised. 6. The daily brushing of the teeth and washing the mouth with some form of mild antiseptic solution was encouraged. 7. Individual towels and soap were given to each child. 8. The children were bathed frequently and the clothing was kept scrupulously clean. Each child was given a clean piece of white muslin every day to be used as a handkerchief. 9. An examination by the nurse was made of each child every morning, and whenever any fever was found the institution physician was immediately called and he in turn notified the institution inspector of the Health Department, if necessary. If any evidence of a con- tagious disease was discovered, the child was immediately placed in quarantine. No child was allowed to remain in the dormitory if sick. At the beginning of the epidemic of poliomyelitis, the Department of Charities and the various Children’s Courts of the City were communicated with and were requested to notify the Health Department when a child was committed to an institution. A daily report was received, giving the name of the child, address whence it came and the name of the institution to which it was committed. The child was examined by an inspector of the Department of Health on the day after it was assigned to the institution and again after the expiration of the two weeks’ quarantine, before being allowed to go to the dormitory of the institution proper. REGULATIONS OBSERVED BY THE INSTITUTIONS, AT THE DIRECTION OF THE DEPARTMENT OF HEALTH. 1. Every child must be examined by an inspector of the Divi- sion of Institution Inspection on the day following its arrival at the institution and again after the expiration of two weeks, before being admitted to contact with the other inmates. 2. Visiting children by parents, guardians or relatives is tempo- rarily prohibited. 3. Food, articles of clothing or toys must not be brought to the children by parents or friends during the present epidemic of poliomyelitis. 4. Permission to children must not be given to visit relatives or friends in the city and return to the institution. 5. Children must not be permitted to attend public gatherings. 6. Unnecessary grouping of the children of one dormitory with those of another is to be avoided. 7. Every child showing evidence of being ill must be removed immediately to the institution hospital and not be allowed to remain in the dormitory. If the physician suspects any contagious disease, he is to notify the Health Department at once, and an inspector trained in the diagnosis of infectious diseases, will be sent to examine the patient. 8. Employees living outside of the institution must change their clothing before mingling with the children. 9. Every child going to an institution from its residence in the city for a temporary stay, must have a certificate from a physician 23 (and a certificate from the Health Department showing that no cases of poliomyelitis have been reported at the address given) before being admitted to contact with the other children. An inspector of the Health Department must also examine the child on the day of its admission to the institution, and again before allowing it to return home. On July Sth, specific instructions were issued to the inspectors and nurses in charge of the 59 Baby Health Stations and these were further supplemented on July 10th. 1. All known or suspected cases of anterior poliomyelitis coming to your attention, are to be reported to this office on the white filing card, giving the name, age, address, floor, duration of illness, and name and address of physician in attendance. Prior to this written communication, please telephone to the clerk-in-charge of the Division of School Medical Inspection, the above particulars, and note on the filing card above mentioned, the fact of such telephonic communication. 2. In cases where anterior poliomyelitis exists in the family, the babies may be enrolled, but they must not be allowed to visit the station. The mother or other member of the family may secure milk at the station, and if advice and instruction are necessary, the inspector or nurse should visit the home. . This situation is to be treated as are other contagious diseases, at present. 3. Rabies living in houses in which anterior poliomyelitis exists but not in the same family, may be enrolled in the regular manner. During this epidemic all the nurses and inspectors should impress the mothers with the necessity of absolute personal and home cleanli- ness, with the danger of allowing refuse to remain around the house, with the importance of covering garbage cans, the necessity of keep- ing children away from others as much as possible; the dangers of coughing, sneezing and expectoration; the danger of flies as trans- mitters of the disease; the importance of nasal hygiene ; the advisabil- ity of securing immediate medical care when the child is taken ill, especially with fever, vomiting, drowsiness or weakness of the ex- tremities, and of isolating such a child from the rest of the family. Impress, furthermore, upon the parents, the importance of quar- antine, in true cases, and ask them to report to you any suspicious cases which come to their attention. Each and every one should feel her personal responsibility in the effort which is being made to control an epidemic which threatens to assume large proportions. : All contemplated outings of mothers and babies must be can- celled. (July 10th) 1. Look over the daily list of contagious diseases immediately upon your arrival at the station each morning, and note the name and address of all cases of anterior poliomyelitis listed in your station district. : 2. Record on a large sheet, in alphabetical or street order, the name and address of every case of anterior poliomyelitis recorded on 24 the lists since June 1, 1916, and continue this daily until further notice, adding such names as appear on the daily contagious disease lists. 3. Arrange to have mothers or other members of families in which a case of anterior poliomyelitis exists, and who visit the station for the purpose of obtaining milk, call for the milk either early in the morning or at the close of the morning. See to it that the milk is given to them at once, and that they leave the station immediately. Under no circumstances must persons living in infected premises, who come for milk, be permitted to mingle unduly with the regular clientele. 4. Enrolled babies from infected houses, but not from infected families, must be instructed and treated, and given preference over others in attendance at the station, and thus disposed of as quickly as possible. : 5. All employees—inspectors, nurses, nurses’ assistants—must report immediately by telephone to the clerk-in-charge of the Divi- sion of School Medical Inspection the name, address, floor, duration of illness, and name of physician in attendance, if any, of all non- placarded true or suspicious cases of poliomyelitis coming to their attention. This clerk will telephone report of case to the Bureau of Preventable Diseases. If corroboration of diagnosis is necessary, the inspector or supervisor should visit the home. This telephonic com- munication must be followed by a full statement of the above par- ticulars on a white filing card, and forwarded to the Central Office, Division of Baby Welfare. 6. All employees, when making home visits, must instruct and advise the public in preventive measures, as outlined in the instruc- tions under date of July 5, 1916. 7. Should any child ill with anterior poliomyelitis visit the sta- tion, he or she must be excluded at once, the particulars of the case telephoned immediately as above outlined, and the mother instructed to take the child home and isolate it from other members of the family. UnN1tEp STATES PuBLic HEALTH SERVICE ASSIGNS SpeEciAL Corrs OF INVESTIGATORS: On July 6th, the Secretary of the Treasury in person offered to the Mayor the assistance and co-operation of the United States Public Health Service. The offer, which was gratefully accepted, resulted in the assign- ment of eleven officers, one epidemiologist, and one biologist to the work in and about New York City. By conference between the officers in charge and the Department of Health, it was agreed that the Public Health Service should undertake certain field and statistical studies of the disease for which the Department of Health was not at that time equipped and for which the personnel of the Public Health Service was exceptionally well qualified. Laboratory studies were found impracticable for various reasons and this phase of the investigation by the Public Health Service was carried on at the Hygienic Laboratory at Washington, D. C., with material sent from New York City. It would be inappropriate to include in the report of the 2 Department of Health of New York City the results of these admirable studies which will appear in the official reports of the Public Health Service. We have been allowed, however, to publish as part of this report the statistical tables prepared by these collaborators. STATEMENT BY THE MAYOR. On July 9th the Mayor called a conference of his commissioners to consider in what ways the entire force of the City Government might be used for protection of the public. The departments particularly concerned, in addition to the Health Department, were the Police Department, Tene- ment House Department, Department of Street Cleaning and Department of Water Supply, Gas and Electricity. The following statement was issued in the press the next morning and did much to quiet the growing public alarm, and give confidence that no effort would be spared: “All Resources of the City Mobilized in Fight Against Paralysis. “ Although very little is known of the origin or transmission of infantile paralysis, I am advised by the health authorities that all scientific experience points to the fact that it is communicated by direct personal contact, and that the germs do not live apart from the human body; in other words, that it is necessary for a diseased person, or one who has been in contact with a diseased person to come in turn into contact with a susceptible individual in order that the disease be communicated. “Cases Segregated. The Health Department is now bending every energy night and day to prevent the spread of the infection through such contacts as just described. This it is doing by segre- gating the cases in hospitals, as rapidly as the diagnosis can be posi- tively made, and by educating the people in the method of preventing personal contact by personal cleanliness. “ At the same time, we have called into co-operation the national health services to aid in tracing the origin of this epidemic, and in determining more accurately than our present knowledge permits, the method of transmitting the disease. “In the meantime, and whatever the method of transmission may be, I have determined that every precautionary measure in the nature of clearing out refuse from halls, areas, yards and cellars, its collec- tion and immediate removal from the streets shall be taken in so far as the city government has the power to enforce the action. “ Accumulations of refuse containing garbage in the public streets at various points in the congested districts have been reported during the last few days. These are conditions that exist continu- ously in the congested districts and are solely the product of viola- tions of city ordinances by householders, who, despite repeated warn- ings and all that we can do to the contrary, insist on throwing the refuse into the streets in place of collecting it in proper receptacles as provided by law. A real city clean-up, with the maintenance of cleanly conditions, can be effected only if householders will co-op- 26 erate by observing these ordinances forbidding the spreading of refuse in the streets. “ Receptacles for Garbage. I wish to make it perfectly clear that the Street Cleaning Department is not responsible for the refuse which can be found any morning lying in the streets of the congested districts, and that it discharges its duty by removing that refuse as soon as the carts and men of the department reach these streets in the course of their regular day’s work. “ Householders are also required by law to maintain watertight and properly covered metal receptacles for garbage, and to deposit rubbish securely tied in bundles so that it will not spread over the streets. “I have directed the Police Department to enforce rigidly these ordinances. I have specifically directed that any householder, store- keeper or other person found depositing garbage or rubbish in the streets in violation of these ordinances is to be arrested and arraigned before a Magistrate. I am requesting the Chief City Magistrate to urge all Magistrates in the city to co-operate with the city authorities in enforcing the law, and to impress its importance upon violators by adequate penalties. “TI have further directed the Tenement House Commissioner to utilize all the resources of his department to compel the cleaning up of halls, areaways, cellars and yards throughout the city. “T have directed the Street Cleaning Commissioner to accelerate to the limit of possibility the collection of garbage, ashes and refuse properly deposited in receptacles and to continue to clean from the streets such refuse as may be thrown there in violation of law. This is done by the Street Cleaning Department every day at the present time, but we propose to attempt to complete the work somewhat earlier each day than at present. “More Water for Streets. ‘There is no more important feature of the work of the Department of Street Cleaning at the present time than that of street flushing. This is a very useful way of using water, provided it be not wasted. Every possible effort is made to supervise the individual street cleaners so that they shall not use the hose longer than necessary on any one spot, though it is unfortunately often difficult to control their individual operations. In due course it is hoped to rectify this condition. Meanwhile it should be re- membered that not over one per cent. of the total amount of water consumed daily is used for street cleaning, while elsewhere amongst private consumers there is a preventable waste of from ten per cent. to fifteen per cent. of such total. “The Department of Water Supply has been co-operating with the Department of Street Cleaning in this matter throughout the present administration. I have directed its further co-operation in the present situation in order that still more water may be available to the Street Cleaning Department, to the end that the streets includ- ing sidewalks particularly in congested districts shall be thoroughly washed down each day. “The Street Cleaning Department will increase its night work in Manhattan, so that every street will be cleaned every night. In Brooklyn where the epidemic has been most severe, a number of hose gangs employed in night flushing will be increased from 15 to 27 40 in the infected area. Night work will be increased by 50 per cent. To do this the Street Cleaning Department must reduce its force employed in the daytime and unless property owners will co-operate by avoiding the present general widespread violation of ordinances in the matter of littering the streets with refuse, there undoubtedly will be an increase in the unsightly appearance of streets during the day- time. Here I expect particularly the co-operation of the Police De- partment through the rigorous enforcement of the ordinances. “In short, it will be the effort of the city government during the continuance of the epidemic of infantile paralysis to focus all its forces on a general clean-up as a means of reducing the possibility of the spread of the disease. Resources of the Health Department, Street Cleaning Department, Police Department and the Department of Water Supply and the Tenement House Department will all be employed to this end. “There is no occasion for alarm or panic. The careful observ- ance of the simple directions given by the Health Department as to personal and household cleanliness will go far to prevent further spread of or exposure to infection. “I wish to urge citizens to permit the removal of their sick chil- dren to hospitals selected by the Department of Health. The death rate in this epidemic has been appreciably lower in hospitals to which patients are taken for the sake of isolation than in patients’ homes where adequate care cannot be provided.” The result of effective co-operation was soon evident, and, according to the critical opinion of the inspectors of city departments and of careful and observant citizens, the highways and premises of the city were never in so clean and wholesome a condition as everywhere prevailed through the re- mainder of the summer. Private Hospitars Co-OPERATE. On July 10th it became quite apparent that with at least four weeks more of increase in the number of cases to be expected, and a daily report of about 100 cases, the capacity of the hospitals of the Department of Health would soon be reached and either additional hospital beds must be obtained, or the policy of hospitalizing the cases must be abandoned. The hospitals of the city were appealed to by the Mayor, and within a week enough beds had been promised to accommodate the expected census of patients. Separate wards were in most cases made available and conducted ac- cording to established practice for the care of communicable diseases. In two notable instances, complete hospital establishments were put at the dis- posal of the Department of Health. The Health Officer of the Port offered the use, for patients from the Borough of Richmond, of the isolation hos- pital at Swinburne Island, with a capacity of 75 patients. With certain supplies and personal service contributed by the Department of Health, the wards were immediately made available, and throughout the remainder of the epidemic the necessity of transferring more than a small number of 28 cases from Staten Island to Department hospitals, in other Boroughs, was avoided. The New York Hospital, having its children’s wards filled to capacity, but wishing to make its contribution to the service of the City, offered to occupy and maintain a hospital with one hundred and six beds in the building recently vacated by the New York Orthopaedic Hospital, in East 59th street. The use of the building was given to the New York Hos- pital, through the Department of Health, by the Orthopaedic Hospital, and the New York Hospital promptly installed the necessary staff and equip- ment, even to the point of establishing a pathological laboratory for research purposes at the hospital. The public spirit and resourcefulness shown by the 28 hospitals, which put at the disposal of the Department of Health a total of 726 beds, cannot be too highly praised. By their co-operation they played an important part in the method of sanitary control of the disease which had been undertaken by the Health Department. Bellevue Hospital and the hospitals of the Department of Charities provided a maximum of 660 beds. No attendant, physician, nurse or domestic, and no patient admitted to any of the hospitals throughout the city, for other cause than poliomyelitis, during the epidemic, contracted poliomyelitis. This has been the almost universal experience in the past, and has often been brought forward as a proof of the non-communicable character of the disease. In the minds of those who have studied the disease in the field, this experience would rather indicate that the simple methods of ward cleanliness and the usual technique of personal care employed in hospitals suffices to prevent communication of the disease, and this opinion is borne out by the experience in institutions for children where similar simple measures prevented the spread of the disease. One of the field nurses of the Department engaged in daily house to house visits among the families where active cases were isolated developed poliomyelitis in a severe paralytic form. The City paid at established rates for the care of patients admitted to the hospitals above mentioned. A complete statistical record of the services of these hospitals is to be found on pages 261, 262, and 263. CONFERENCE OF PHysiciANs CALLED BY THE MAYOR. On July 12th the Mayor requested the opinion of members of the Advisory Medical Board of the Board of Health, and of a number of other prominent scientists and sanitarians as to further means of checking the spread of the epidemic. A sub-committee was appointed, which met the following day, and decided that no further administrative or educational measures could be expected to produce any beneficial results, but reported that it would be advisable to take such steps as might prove practicable to discover, trace and keep under observation persons who might have been in immediate contact with those sick with the disease. In other words, the sub-committee advised the Mayor that some additional knowledge might be 2 expected from an intensive study of the contacts and secondary cases occur- ring throughout the city. Inasmuch as this was in the nature of experi- mental field work, which the Department of Health was not at the time free to undertake, the Mayor accepted the offer of the Rockefeller Foundation to defray the cost of the proposed investigation. The entire personnel of the field and office force, together with the director, was put upon the pay- roll of the Department of Health, and the funds provided by the Rockefeller Foundation were disbursed through the Department of Health on vouchers signed by the Director, the Vice-Chairman of the committee in charge (the Mayor, Dr. Simon Flexner, Vice-Chairman, Dr. Haven Emerson, Dr. W. B. James and Dr. G. R. Butler) and by the Commissioner of Health. The work was undertaken soon after and a report of the results will be found on page 111. On July 13th the special poliomyelitis field corps of the Department was further increased by 40 medical inspectors and 10 nurses. TRAVELLERS’ CERTIFICATES. On July 14th there was undertaken for the first time a new procedure which developed into such large proportions and caused so much public comment, chiefly of adverse character, that it deserves special mention. Owing to the local restrictions adopted by various health boards in many adjacent states and communities, within easy travelling distance by rail, boat, or motor, from New York, which were in the nature of honest but impractical attempts to ward off the approach of infected individuals from New York City, healthy adults and children from the city were subjected to inconvenience, great injustice and even to inhuman treatment. Rail- roads and other common carriers appealed for assistance and it was de- cided that so-called health certificates, or more properly travellers’ identifica- tion cards, should be issued to those who presented themselves at certain offices of the Department of Health for medical inspection and could prove residence at an address from which no case of poliomyelitis had as yet been reported. Between this date and July 18th these certificates were issued by the Department of Health, and only after examination of the applicant by a physician of the Department. On July 18th, 25 officers of the Public Health Service were assigned by the Surgeon General to the control of inter- state transportation in the interest of preventing the spread of the disease. Later, twelve more physicians were added to this staff, all operating under Senior Surgeon Charles E. Banks. The supervision of travel, as enforced under the provisions of the interstate quarantine regulations, was as fol- lows (extract from report of Senior Surgeon Banks) : “Children 16 years of age, and under, were placed in a class of restricted travel and were not permitted to leave the city from July 18th until October 3d, without producing a certificate that the prem- ises occupied by them were free from poliomyelitis, and had been 30 free from this disease since January 1, 1916. This was supple- mented by a medical examination of such travellers at the point of departure. When these requirements were satisfactorily shown, a certificate of identification was issued, together with a duplicate of same immediately mailed to the health officer of the community to which the travellers were destined. As required by law, common carriers (railroads, steamboats, etc.) were obliged to refuse entrance to trains or boats of this restricted class unless so provided with the certificates. The essential basis of this certification was the informa- tion furnished by the New York City Board of Health covering the immune condition of the premises of intending travellers, and full credence was given to this aid in the execution of the measures undertaken by the Public Health Service in preventing the spread of the disease through interstate travel. “These regulations were enforced at every rail or ferry termi- nal, and steamboat pier, in New York City, and as far as possible automobile traffic leaving the city by other avenues was included.” The objects achieved, from the standpoint of those engaged in this work in New York City, may be stated as warranting the following con- clusions : First. There resulted a stabilization of public opinion through the pres- ence of regular officers of the United States Public Health Service, trained in the management of epidemics, who were assigned to duty in New York City. This was crystallized through the uniform approval of the metropolitan press, with its continuous favorable references to the work accomplished. Second. The work affected a standardization of methods adopted by local quarantine officers of other states through co-operation with the plan of certification above described. Harsh restrictive measures had been adopted in many localities because of the absence of knowledge of the extent of the epidemic and lack of information of the origin of travel into their com- munities. Third. It afforded the local health authorities a certain security in locating arrivals in their jurisdiction immediately, and instituting such meas- ures of isolation, or limitation of movements for a given period as they deemed wise. Finally, it constituted a demonstration of the need of a centralized au- thority, with power to deal with interstate problems relating to the trans- mission of disease by common carriers, backed by congressional statute. The Quarantine Law of February 15, 1893, was the keynote to the adminis- tration of the work of the officers of the United States Public Health Service in the measure employed by it of certification and notification to health officers of travel to their localities. 31 ForM OF TRAVELLERS IDENTIFICATION CERTIFICATE ISSUED. DEPARTMENT OF HEALTH City oF New York I hereby apply for a certificate that there has been no case of poliomyelitis at my address.......cccisnenins 3 Borough of... i wx ws vn vin sin (Signature of Applicant) This is to certify that the records of the Department of Health of the City of New York show that no case of poliomyelitis has been reported from.......... cot... ) Bovotigh of vv. cv vind wun avins svn (Name and Title) On July 15th the Police Department was requested to report all re- movals of families within the city or to points outside, so as to facilitate the tracing of contacts and reported cases which disappeared before the diagnosis was confirmed. On July 20th it was found necessary to follow up the cases isolated in their homes with much more care, as repeated instances of violation of quarantine were reported. To this end, 35 motorcycle police, obtained by a call for volunteers, were assigned by the Police Commissioner to the Health Department. They called on all home cases every other day, alter- nating with the visits of field nurses of the Department of Health. CONTROL OF PLAYGROUNDS. This day saw also an organized effort, for the recreational facilities for children, take definite form and produce substantial results, as con- fidence in the safety of the playgrounds took the place of suspicion and panic. As soon as the quarantine regulations in regard to poliomyelitis were put into effect, it became increasingly evident that the usual work performed by the Department of Health and various agencies of the city, relative to fresh air outings for children, would be appreciably checked. In fact, almost immediately towns outside New York City refused to accept any children sent from the city. In consequence, summer camps were closed, fresh air outings stopped, and, in many instances, children were barred from playgrounds and public baths. 32 All child-welfare workers were keenly alive to the danger that threat- ened, and the Fresh Air Federation of New York took immediate steps to meet the situation. The Department of Health, in co-operating with this federation, devised ways and means whereby substitutes were found for the fresh air outings so generally relied upon during previous summers. The reports of the various settlements and of the Fresh Air Federation of New York will give in detail the individual work done by these organizations. In this survey it is only necessary to state that, while a far greater number of children were kept in town during the summer than during previ- ous summers, it was possible, through the joint efforts of the Fresh Air Federation, the Department of Health and the Department of Education to open public shower baths in the various schools of New York City. In this work the Bath Committee of the office of the Borough President of Manhattan co-operated very closely and the Board of Education’s Com- mittee on Care of School Buildings was informed that the Fresh Air Federa- tion was willing to operate the school baths if permission could be obtained simply to open the school buildings for the purpose. It was found that about forty of the public schools in Manhattan were equipped with shower baths but that the program of the Board of Education provided for the opening of only about half this number. Under the auspices of the Board of Education there were twenty-two baths in Manhattan, one in The Bronx and seven in Brooklyn open for the summer of 1916. Through the efforts of the Fresh Air Federation, eight additional baths were opened. In addi- tion, all baths operated by settlements were widely used. Energetic efforts were made by the Fresh Air Federation to increase the out-of-town facilities for fresh air parties, but marked resistance was met in this direction. Quarantine against New York was rigidly main- tained by practically every town within reasonable distance of New York City, and the only solution of the problem seemed to be educational work which would induce mothers to take their children outdoors, and the provi- sion of proper play space. Such work was carried on with vigor by the Department of Health and the various fresh air agencies. During the early part of the summer, the authorities in charge of the various playgrounds and recreation centres for children of the city were impressed by the possible danger that these places afforded for the means of transmitting poliomyelitis, consequently a considerable number of them were closed, although no order had been issued by the Department of Health to this effect. As it was felt that the use of these recreation centres was of the utmost importance in providing the necessary fresh air and play space for children, investigation was made by the Department of Health to determine whether or not the playgrounds and centres were being oper- ated in accordance with the regulations of the Department of Health, rela- tive to (1) the use of the daily contagious disease lists and (2) the provi- sion of proper medical supervision. It was determined that these playgrounds and recreation centres could 265 tangible results. If paralysis develops after the use of serum, the following points should be noted: 1. The number of doses and amount of serum used each time. 2. The group to which the serum belonged. 3. The number of days the patient has been ill. 4. The number of hours or days which have elapsed since the first dose of serum was given. 5. The degree of paralysis. 6. The rapidity with which the paralytic phenomena begin to clear up. ] 7. The final result; recovery, paresis or paralysis, stating the actual groups of muscles affected. It is only by comparing a large group of early cases treated with immune serum, with normal human serum, and with no serum at all, that we shall be able to arrive at any certain data as to the efficiency of the serum treatment. To help in the diagnosis of early cases the symptoms and findings in the spinal fluid are of value. The macroscopic changes in the spinal fluid, already described, cannot replace the more careful laboratory examinations, but are found to be of great service clinically, especially where immediate facilities are not at hand, and the diagnosis of poliomyelitis has to be con- firmed for purposes of isolation and treatment. Having established the diagnosis in the early cases by clinical symptoms and examination of the spinal fluid, the next step is to inject the serum into the spinal canal. It is here that the bedside confirmation of the diagnosis by the macroscopic appearance of the spinal fluid becomes most important. Where the spinal fluid indicates the presence of the disease on macroscopic or microscopic observation the serum can be promptly administered without any further delay for laboratory examination and without the necessity of another lumbar puncture, although the confirmatory laboratory examination should be made later. Fifteen c.c. of the serum is injected by the gravity method after the removal of a slightly larger amount of spinal fluid. The dose is repeated every 20-24 hours until two, or possibly three, injections have been made. In the more severe cases, especially with an advancing involvement of the respiratory muscles, the serum has been given every 12 hours. In consider- ing the frequency of the repetition of the dose, and especially of the interval of time between the injections, it is important to remember what is taking place in the cerebro-spinal meninges after an injection of the serum. A marked polynuclear cellular reaction is produced, which probably should be given time to exert its full effect before the spinal canal is tapped again and the rich cellular fluid removed, for the administration of a second or third dose of serum. If the reinjection of the serum is delayed, however, 48 hours or longer, there will be noticed a rapid clearing up of the arti- ficially produced cellular increase in the spinal fluid. Considering this therapy as a possible non-specific cellular stimulation obtained by the injec- 266 tion of a rich protein fluid, we would consider that an interval of 20-24 hours between the injections is best, but it is fair to state that in three severe cases the readministration of the serum was made every 12 hours with apparently good results. The serum is rapidly absorbed from the spinal canal, so that one daily repetition of the dose is indicated, especially if the efficiency of the serum is considered as being based in part upon its antibody content. - Source of Serum—Groups of immune serum. The immune serum used in the treatment of cases of poliomyelitis was obtained from convalescents and from donors, who had had the disease from one to several years previously. For the sake of accuracy, and to facilitate the proper study of its action, the serum has been classified into groups, according to the months or years which have elapsed since the im- mune donors had the disease. It is important in choosing donors for im- mune serum to establish the fact that they had really suffered from infantile paralysis, and not to accept the diagnosis of the donor on his word, as cases of Bell’s palsy, tuberculous disease of the bones and joints, hemiplegias, syphilitic and otherwise, will frequently be found among so-called “immune donors.” The groups into which the serum has been divided are as follows: Early convalescent serum......... from 2 to 6 months after an attack Late convalescent serum... .......x from 6 to 12 months after an attack GIOUP A SEIU. oo. isis ow viiediam sie from 1 to 5 years after an attack Group B Sera, o.oo + viniis imei from .5 to 15 years after an attack Group Clserum. on ve st bins + from 15 to 30 years after an attack Group serum’... ii vies from 30 years up after an attack Method of Obtaining and Preparing the Serum— (a) Amount. To obtain the immune serum the blood is drawn from suitable donors in quantities varying with the age, weight and apparent hemoglobin content of the individual. On an average, it is safe to withdraw 2 oz. from children 9 to 10 years of age, 3 to 4 oz. from children 12 ta 13 years of age, 4 to 6 oz. from individuals 18 years of age and over. Adults, especially robust, full-blooded persons, can furnish 10 to 16 oz. of blood. Similar amounts of blood can be safely withdrawn again at the end of two to three weeks. (b) Technique of Obtaining the Blood. The blood is obtained either by means of a No. 15 gauge steel or platinum needle, to which a small piece of rubber tubing is attached. In children, adults and stout individuals with small or indistinct veins, the blood is withdrawn by means of a 1-0z. Record Syringe and a No. 17 gauge needle. The blood is collected in small square bottles in quantities of 1 to 2 oz., and given a long slant so as to obtain as broad a surface for the separation of the serum as is possible. (¢) Preparation of the Serum. The blood is allowed to clot, and the bottles are then placed in the ice-box during the following 267 twenty-four hours to allow a separation of the serum. This is de- canted the following day and centrifuged to free it from pieces of blood clot and red blood cells. To the serum is next added a pre- servative in the form of 0.2 per cent. trikresol.* This is added in a 25 per cent. solution in quantities of 4 c.c. to every 500 c.c. of serum. The serum is then allowed to remain in the ice-box for forty-eight hours, so that a fine precipitate, which forms after the addition of the trikresol, separates out and is removed. The serum is then passed through a Berkefeld stone filter, either by suction or pressure, bottled in quantities of 15 c.c. in dark amber or blue bottles, and kept cold in the ice-box. (d) Duration of Efficiency of the Serum. If the serum has been preserved with trikresol, or handled with sterile precautions after it has been passed through the Berkefeld filter, and is afterward kept in a cold place, it will probably remain efficient in its specific content for a number of weeks. The serum obtained was used up almost as fast as it was obtained. Some of the serum which was kept for four to six weeks seemed to be as active, therapeutically, as the more recently drawn serum. ; In an emergency, or where the facilities for treating the serum are not obtainable, the blood is simply drawn under aseptic conditions in a vessel with glass beads and shaken and centrifuged ; or the serum, drawn in the usual way, is allowed to separate during the next few hours, and promptly used, disregarding entirely the presence of the few suspended red blood cells. If a further experience justifies our opinion that immune serum is beneficial, it will probably be found that the results are due partly to specific immune serum and partly to normal human serum as such. If this con- clusion proves to be true, when specific immune serum is not obtainable, it will be advisable to use normal human serum, when possible, which can easily be obtained from parents or relatives of the patient. It is important to note that in the preparation of serum, either for stock, or fresh without a preservative, no heat is applied either for inac- tivation or for sterilization. Each donor should be otherwise healthy and give a negative Wasser- mann reaction. ~ Results of Serum Treatment. The most evident action of the serum is a marked cellular response of the cerebro-spinal meninges in the presence of the serum injected by lumbar puncture. This cellular reaction consists of a very decided increase of the polynuclear cells, which preponderate in some of the cases to the extent of 95 per cent., while the total cell count increases from 500 to 10,000 per cubic centimeter. This increase of cells is at times so pro- nounced that the spinal fluid obtained at the end of 24 hours has a very marked turbid, almost purulent appearance and a heavy sediment of cells * The trikresol increases the local irritant action of the serum, and it may be found advisable not to add it as a preservative. 268 is found in the test tube within a few hours after the lumbar puncture. Culturally, these fluids are always sterile. This cellular response is found also after the injection of normal human serum, of normal horse serum and of the secondary albumoses of Jobling, when these sera are used in the same early stages of disease. This high reactivity of the cerebro-spinal meninges is probably due to the very marked congestion of the vessels of the pia-arachnoid, and of the cerebral cortex. It is probable that in the use of immune serum we have, in addition, the assistance of antibodies against the virus of poliomyelitis, which stimulate the polynuclear cells to increased phagocytic activity. We cannot estimate the phagocytic action of the cells, as the virus is too minute to be seen. It must not be overlooked, however, that we have probably obtained therapeutic results as good after the use of serum from Group C or Group D as from Group A or B. Such sera may have only a problematic value as antisera, and almost their entire action may depend on the rich protein content of all blood sera. Further experi- mental work will, no doubt, have to be carried out in monkeys to determine whether the injection of immune sera into the spinal canal of monkeys will have a greater protective value against a previous infection with active virus than the injection of normal human sera. If the injections of immune or normal human sera are made in the later stages of the disease, when the temperature has already subsided, the cellu- lar response will be found much poorer, and only an opalescence of the spinal fluid will be noticeable at the end of 24 hours. This lessened cellular response is probably due to a subsidence of the acute congestion of the brain and meninges. Clinically, the injection of immune and of normal human serum is fol- lowed, within 24 hours in the early pre-paralytic cases, by an intensification of the meningeal symptoms. Increased rigidity of the neck, opisthotonos, marked Kernig, hyper-irritability, headache, vomiting and increased tem- perature, which reaches in the most severe reactions up to 104 or 105° F (See chart I, page 269.) At times where the reaction is especially severe we have twitchings or even convulsive movements of the extremities. These symptoms represent merely a more severe degree of the early pre-paralytic phenomena of the disease. In some of these cases the temperature is simply caught in its upward rise and, therefore, it has no significance. Definite temperature reactions have, however, been noted after the primary and also after secondary injections of serum. The typical curve can be seen from the following chart: A rise in temperature, persistence for another 24 hours, without any further increase after a second dose of serum and subsidence by a rapid lysis. (See chart II, page 271.) The other symptoms, the rigidity of the neck and Kernig persist for two-three days after the temperature has dropped to normal. Gradually the symptoms clear up and the patient, if there is no complicating paralysis, makes a rapid and uneventful convalescence. TEMPERATURE CHART I. pe Two temperature curves in cases of poliomyelitis that received immune serum. Figures at top of chart indicate duration of disease since day of onset. 273 The cases treated with immune serum may be divided into three groups: 1. Cases treated at the Willard Parker Hospital. 2. Cases treated at the Minturn Hospital. 3. Cases treated with other physicians. I. Willard Parker cases— A—Immune serum cases: (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-paralytic Cases—25 Cases. Type of Serum. Number of Doses. Aoi imerortainany io One’ cove odansh inhins 20 BS evita nin 1 TWO, wisi Bibles 4 Brio dives petite ads 17 Three sicily vir dois 1 Doviinrecaqransrases 7 £= 3s 25 gs REesuLTs. (1) Remained free from paralysis.............. 24 (2) Weakness of both quadriceps extensors... .. 1 {BY Del Jina dam alsh rrvss seuss Bet unis siras 25 (b) Paralytic Cases—88 Cases. (LY Died, colubrid dannii ae Abril ee 38 (2) Lived is vivian Ba i Sa ven sins aes 50 Of the 38 who died: 18 died in less than 24 hours after first dose of serum, 9 died within 48 hours after first dose of serum, 5 died in more than 48 hours after the first dose of serum, 2 died of tubercular meningitis, 1 died of gastro-enteritis, 3 died of pneumonia. Type of Serum. Convalescent ........ 1 Aldine 4 Bille. Yalsicaiinia 10 SEARS ORIEL SS 23 38 No. of Doses. OnE] win iviinn saninss 23 TWA. 0 eal 13 Three. ulus 2 * Found to be tuberculous on autopsy. Type of Case. Bulbar. vc eeieies 7 Bulbo-spinal ...... 6 Spinal. ..ol ans 22 Cerebral .. Jui cans 1 *Tuberculous ...... 2 38 A large proportion of the fatal cases were children in the last stages of an advancing Landry type of poliomyelitis. Of the 18 that died within less than 24 hours, a majority were moribund cases and died within a few hours after the administration of a single dose of serum. Many of the 274 patients in this group received the serum only as a last resort. The bulbar cases had well-pronounced respiratory difficulty before the serum was injected. ; There were 50 who lived. Type of Serum. No. of Doses. Type of Case. Convalescent ...... 1 OnGis.civn ss cinmls inns 39 Bulbar vise arse 8 Bhi esas ins 6 WO 000i 1 abichninns 9 Bulbo-Spinal ...... 2 ER A 2A Thee... Sivan 1 Spinal oh san 40 Ch end 20 Four hs iis visntvenis 1 Cerebial- Jo... 00s gh BD ...... ......... 2 — — — 50 50 50 These cases already had a well-developed paralysis when treated, but were in a still active stage of the disease, as shown by temperature and a spreading type of lesion. These children recovered and showed a definite clinical improvement. It is impossible to determine how much of the im- provement, which is also generally seen in the untreated cases, was due to the administration of the serum and how much would have taken place dur- ing the natural course of the disease. B—Normal serum cases. To determine whether a similar cellular reaction would be produced by the intraspinous injection of normal serum and whether similar thera- peutic results could be obtained, a series of pre-paralytic and paralytic cases was treated with serum obtained from individuals who, to their knowledge, had never had poliomyelitis. It is, however, recognized that persons who have never shown any paralysis may have protective substances in their blood. The serum was used in the following: (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-paralytic Cases—10 Cases. No. of Doses. Results. One... 0 a, ¥ Bemzined free from paralysis. iii cviime canines 9 WO i iininns 3 Developed bulbar symptoms within 12 hours and — IB I tee dike re he inte uaa pea Bde 3 10 —_ ) 10 (b) Paralytic Cases—33 Cases. GUY DIed Celanese hos x rvs eM wey 5 (2) Tdved iv. En an vias ad hae 28 Of the 5 who died: 3 died within less than 24 hours after first dose of serum, 1 died of sepsis, 1 died of pneumonia. No. of Doses. Type of Cases. 275 In two of the children who died within less than 24 hours the disease was of the advanced ascending spinal form of the Landry type; in another it was of the bulbar type. There were 28 who lived. No. of Doses. There was a distinct clin but whether more than would cannot be properly claimed. Type of Cases. Bulbar™.......con0. ical improvement in the cases that recovered, naturally take place without the use of serum II. Minturn Hospital Cases— These can also be divided into two groups: a—Pre-paralytic cases. b—Paralytic cases. a. Pre-paralytic Cases—15 Cases. Type of Serum. No. of Doses. A RE OneR fii ol wails Bs sh dens sities siaies 5 Two... cl ia 11 Cringe vain nes 1 Three oa, siden 2 Dos aihineas 1 Four iranian 2 IE 13 Results. (1) Remained free irom paralysis. oviviaG i voivaniin, 9 (2) Developed paralysis within less than 24 hours........ 2 {a). Bulbar, with complete recovery... .. ...o00 (B) {b) Facial, ‘with complete 7eCovery. cui... vor sa {C) {3) Developed paralysis after 4B hours... cv ius sus 20s 4 {a) Facial with complete recovery... .....coc..... (B) (b) Internal strabismus with complete recovery.... (C) (c) Both lowers and left deltoid, with marked im- PrOYEMEIIL: sais oh ase a Bey Sats vanebe sin attnis 0s {C) (d) Both lowers, both deltoids, with final improve- CTE a ts ers rh es i A Re ME AE {CY This series represents an interesting and valuable group of cases. Each case was fully treated and carefully observed for a period of 8 weeks, and the clinical results in these children lead one to the conclusion that the serum was distinctly beneficia 1 in the treatment of these pre-paralytic cases. b. Paralytic Cases—18 Cases. Type of Serum. AYER cu de LR Sm ey 3 Qi Bn hn, 12 Di ad Fairs fs No. of Doses. Type of Case. OfiE 5 a 5 andes Bulbar.... Li aa. 2 Two... he 7 Spal = a ed 16 Three... ih cai, 2 — FOUL oni whey 2 18 276 Results. Recovered with improvement of paralysis........ 15 Pedr 2. J sit ile Tore Sam iie wie she das iawn we 3 (1) iLandey spinal: cas, se didei din i Toss 2 (2) Bulan tol find she my wn rR re 1 The cases in this group represent mostly the usual spinal type in an active stage of the disease, as shown by the short history and the presence of temperature. The fatal cases were seen and treated at a time when the prognosis seemed to be very doubtful. In addition to the serum treated cases there were at the Minturn Hos- pital 41 cases that received no serum. The majority of these cases came under observation during the stage of convalescence. 111. Cases treated with other physicians, outside of Department Hospitals— These cases were personally observed and treated. (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-Paralytic Cases—14 Cases. B0Ted. i a a ae Be A Rel i Wa he ar We 0 Type of Serum. No. of Doses ER i re i One ve. dan bs 7 Bl eins 2 TWO «le asl to 3 (0 he a eS 7 Three’ JJid ce dovens 4 DF art hs see 2 — — 14 14 Results. Remained free from paralysis............ 11 cases Developed paralysis... oc son suns videos 3 cases (1) Facial and strabismus with complete recovery........ (A) (2) Anterior tibial groups with marked improvement... ... (D) (3) Paresis of both upper eyelids with recovery........... (CC) This group of cases treated in the pre-paralytic stage of the disease is also interesting in the large number of complete recoveries that followed the treatment with immune serum. (b) Paralytic Cases—13 Cases. Type of Serum. No. of Doses. Type of Case. LIRR A 12'One sient 8 Bulbar Si. ent tass Boor. ails, iT Wo vied 2. Bulbo-spinal ue. 1 Gr i sees SHEE des ery Sir Spinal Lars ene -10 Bn na hn 1 — hi — 13 13 13 Results. Recovered with improvement in paralysis........ 9 Ed: os SR i TRE a Si eae a pn tees 4 {il andryspinals cor iinis o55 5 viletens 3 (2) Bulbar at. i ae AL 1 277 The bulbar case died within two hours. It was a far advanced case and the prognosis was poor. Of the three Landry spinal cases, two died within less than 24 hours after treatment. In addition to these cases that were seen personally, the serum was supplied to physicians for over 200 cases. The reports obtained from the physicians are not complete, but the cases reported indicate results similar to those detailed above. Control Cases— It is very difficult indeed to state definitely to what extent the results obtained with serum can be ascribed to the action of the serum only, both as a specific and non-specific form of treatment. As stated above, the natural course of the disease is variable. For purposes of control, there- fore, a series of 12 non-treated pre-paralytic cases was taken, without selec- tion, from the records of the Willard Parker Hospital: Control pre-paralytic Cases... uives vices veteran 12 Remained free from paralysis......... ad 5 Developed \Dardlysis: aw oi desis sitters ions 30 ae 7 (a) Bilateral ptosis with little movement of eyeballs. (b) Complete facial paralysis. (c) Paresis of right arm and left leg. (d) Paresis of right leg. (e) Paresis of neck muscles. (f) Paresis of both quadriceps extensors. (g) Paralysis of both lower extremeties. At the Minturn Hospital there were three non-paralytic cases admitted 8 days after the onset of the symptoms, who remained free from paralysis. Of two pre-paralytic cases, one developed strabismus and one paresis of both lower extremities. SumMmARrY OF Cases TREATED WritH (A)—IMMUNE HumMAN SERUM. Paralysis with Final Recovery. No Institution. Total. Paralysis. Complete. Partial. Died. Willard Parker Hospital... 25 24 1 0 Minturn Hospital. . ...... 15 9 3 3 0 I—Pre- With other physicians. . . .. 14 11 2 1 0 paralytic. Td soem — —_ — Totals ann 54 44 5 5 0 Recovered. Ne Institution. Total. Complete. Partial. Died. Willard Parker Hospital. . . 88 5 45 38 Minturn Hospital. . ...... 18 2 13 3 II—Paralytic.{ With other physicians. .... 13 1 8 4 Total... 119 8 66 45 278 (B)—NormAL HuMAN SERUM. Paralysis with Final Recovery. Institution. Total. Praia Compiier Partial Died. I—Pre- } : paralytic. [Willard Parker Hospital... 10 9 bo I 1 Recovered. tnstitution. Total Complete, Portial.’. "Died. II—Paralytic. Willard Parker Hospital... 33 4 28 3 The above table gives a summary of the cases treated with immune and with normal human serum. It is interesting to see that of 54 pre-paralytic cases treated with immune serum 44 remained free from paralysis, while of the 10 who developed some form of paralysis, 5 made a complete final recov- ery. The results with normal serum seem to be favorable, but the number of cases treated in the pre-paralytic stage of the disease is too small, and a larger series of cases should first be treated before final deductions are made. The high mortality among the paralytic cases is explained by the desperate condition of many of the patients at the time the treatment was administered. The ascending Landry type, with involvement of muscles of respiration, or the bulbar cases, with involvement of the respiratory center, made up the majority of the fatal cases. Of the 102 cases that lived, 12 recovered com- pletely and 90 showed improvement at the time of discharge. AMOUNT OF IMMUNE AND NORMAL Broop OBTAINED DURING JULY, AUGUST AND SEPTEMBER, 1916. Immune Blood: (1) Convalescent blood (early)................. 16 ounces (2) Group A DIo0d. ic. vnriiii sia ois + ros bidpaduiee 77 ounces (3) Group B BIOod. + vv cnn niadie vs 380000 ois 206 ounces (4) EGroup Co Dl00d ic nai sod elie ia vis oto uatisiete 643 ounces (53) Crop DIBION. wees soisl sisi vvis + Onis an 314 ounces Dal tr ln chs aay et ev a As 1,256 -ounces Normal Blood: TE Donors «30s fea be a Ba A Bats fate pe Mines 144 ounces SuMMARY OF RESULTS. It is known that in poliomyelitis we have a group of non-paralytic or abortive cases which go through the premonitory symptoms, but do not terminate in paralysis. It is impossible to state, therefore, how many of 279 the cases treated with serum would have remained free from paralysis without serum treatment. The results and the conclusions from any form of treatment in a disease which is so varied, variable both in symptomatology and in prognosis, as to life and as to function, must be given with reserve. The results obtained seemed to be favorable when the serum was used in suitable cases in the pre-paralytic stage of the disease. Paralysis has been followed in some cases, but the mortality seems to have been influenced by the administration of serum. The later and more severe cases treated after the paralysis had already made a distinct headway and was beginning to involve the muscles of respira- tion, showed, in a certain proportion of cases, an inhibitory effect of the serum upon further progress and a possible life saving result. While no absolute judgment of the value of a serum can be based as yet upon the results obtained, they are, nevertheless, encouraging and justify a continuation of the serum treatment in acute poliomyelitis until, in the course of time, more definite data be available. SERUM THERAPY IN EXPERIMENTAL POLIOMYELITIS. The blood of persons who have survived an attack of acute poliomy- elitis contains specific substances which possess the ability of neutralizing active poliomyelitis virus. This has been demonstrated by Flexner and Lewis, Romer, Landsteiner and Levaditi, et al. It has also been shown that monkeys recovering from an attack of poliomyelitis become refractory to a second inoculation of virulent material, and in the blood of these animals can be demonstrated the neutralizing principles found in the blood of recovered human cases. Netter (1) applied this knowledge in the treatment of a small series of human cases, with perhaps favorable results. His conclusions were not very definite. He administered, intraspinally, from 4 to 12 c.c. of serum obtained from a recovered case whose blood yielded a negative Wasser- mann. It was administered daily for four or five days, or as long as the clinical symptoms indicated its need. One case received eight injections. Zingher (2) treated a larger number of cases by the intraspinal method, using sera obtained both from recovered cases of the disease and from normal persons. His report is favorable to the treatment. No tests were made to determine whether or not the sera obtained from the recovered cases possessed the neutralizing powers necessary to render it specific. Two cases of reinfection in the epidemic of the past summer that had come to our attention may throw some doubt on the assumption that all cases that recover from one attack of the disease are immune to a second infection, or that the blood of all such cases possesses neutralizing powers. However, the testing of the serum of each donor, for the specific prin- ciples would render the whole procedure impracticable, mainly because of (1) Netter, Bull. de 'Acad. de Med., 1914, IXVI, p. 525. (2) Zingher, Journ. Am. Med. Assn., March, 1917. 280 the loss of time necessary to perform this test, and secondarily, because of the expense, for at the present time there is no way of demonstrating this property in serum, except by the injection into a monkey of active virus that had been placed in contact with the serum. From a practical viewpoint the probabilities are that only a small percentage of the cases would give a negative test. Schwarz(3) treated 21 cases with convalescent human serum. Of these, nine recovered without paralysis. Of a series of 21 other cases treated expectantly 17 recovered without paralysis. From this might be inferred that the serum was not of any particular advantage. Schwarz feels that too much was not to be expected of the use of the immune serum. Prognosis in poliomyelitis is a very difficult matter. It will require, ‘therefore, great numbers of cases adequately controlled to gain a true idea of the value of the serum treatment from the clinical viewpoint. The clinical use of the serum of old recovered eases of poliomyelitis is not founded on complete, clear-cut animal experimentation. Its use is in part scientific and in part empirical. Flexner (4) and Lewis performed two experiments, the results of which indicate that a known specific serum may exert a prophylactic effect. An effective dose of active serum virus was injected intracerebrally into a monkey. Within twenty-four hours after the inoculation, and daily there- after, the animal received intraspinal injections of immune serum for a number of days. This animal remained healthy, whereas the control died. Another monkey was inoculated by intranasal scarification with a potent virus. This animal received intraspinal injections of immune serum, within 24 hours after the inoculation, and at three day intervals for a number of injections. This monkey did not exhibit any symptoms of poliomyelitis, while the control died of the disease. The authors state that if the amount of virus injected is not in excess of a certain amount, the procedure de- scribed above will serve to protect animals injected with such a quantity of virus. . The conditions of these experiments, however, do not parallel those which are met with when dealing with actual human cases, where the virus has already become established and is multiplying in the central nervous system, as evidenced by the symptoms of the disease. In this instance, the specific serum can no longer prevent, it must cure. It must counteract and nullify virus that has already become parasitic, and that may have increased in amount, perhaps, in excess of that which can be taken care of by injections of known immune serum. The present work in experimental serum therapy was undertaken in an attempt to supply the conditions that are met with in actual practice. This work comprises six experiments, in each of which were used two animals. One animal was serum treated, and the other acted as control. The virus (3) Schwarz, Archives of Pediatrics, Nov., 1916, Vol. 33, No. 11, p. 859. (4) Flexner and Lewis, Jr., of A. M. A, May 28, 1910, Aug. 20, 1910. 281 was an emulsion of brain and cord material derived from the epidemic of the past summer. Virus of the second generation was used in the first series, and the virus of each succeeding generation was used in the remain- ing experiments. The amount of virus injected was not determined from very much previous experience with this strain. That the dosage was not excessive is evidenced by the fact that two of the control animals, Nos. 37 and 54, and Nos. 23 and 24, not used in these experiments, but which re- ceived the same amounts of virus, survived the disease. The serum used in these experiments was obtained by heart-puncture from monkeys, Nos. 98 and 102. Both of these animals were resistant to the effects of three inoculations of brain and cord material. This material was inoculated in very heavy suspensions, intracerebrally, in the tissues about the sciatic nerves and in the peritoneum. The material, for the first two inoculations, was obtained from two human cases, clinically and pathologi- cally poliomyelitis. The third inoculation was made with material of the second generation monkey virus. These inoculations were given three weeks apart. It was assumed that as a result of these three inoculations, these monkeys were immune and that the blood of these animals ought to contain the specific antibodies. No neutralization test was performed on the sera used in this set of experiments. This, in a measure, parallels the clinical use of serum by Netter and Zingher. In a series of experiments now under way, we shall have the oppor- tunity of observing the effects of known monkey and human immune serum, in the experimental serum therapy of monkey poliomyelitis. Method of Injection. The serum was injected by syringe in doses of 2 to 374 c.c., depending upon the size of the animal and resistance offered to the plunger of the syringe. As much spinal fluid as possible was withdrawn, usually with the aid of the syringe. The first tap yielded up to 2 c.c. of slightly turbid fluid, but subsequent punctures yielded from 4 to 1 c.c. of fluid. The fluids, on being examined, when the quantity was sufficient, gave a globulin test and a definite increase in cells, in one instance, 690 cells per cu. mm. The serum, was injected very slowly and with extreme caution against using any excess pressure. Only one animal exhibited severe effects after the intraspinal injection. This consisted of marked rigidity of limbs, retracted neck and labored and rapid respiration. These symptoms, however, were very transi- ent and within half hour after the injection, the monkey appeared as before the injection. Retraction of the neck was noted after many of the injec- tions, particularly after the symptoms of paralysis had appeared. Time of Injection. The time periods elapsing between the injection of the virus and the beginning of the intraspinal serum injections was so arranged as to be ap- plicable to conditions met with in actual practice. In the Experiments I 282 and II, the serum treatment was begun on the first day of the appearance of any muscular weakness. In the remaining four experiments, serum treatment was instituted before any symptoms had appeared, corresponding to the pre-paralytic stage in the human disease. The protocols are as follows: Experiment [.— Sept. 1, 1916. Rhesus No. 50. Injected with 15 c.c. intraspinally, 2 c.c. perisciatic and 10 c.c. intraperitoneally, of suspension II. gen. virus. Rhesus No. 51, control, received 1.2 c.c. intracerebrally, of the same emulsion. Sept. 6, 1916, No. 50 appeared sick and limped on left leg. Received 31% c.c. serum No. 102, intraspinally. Sept. 7, 1916, 3% c.c. serum No. 102, intraspinally. Limp still present. On Sept. 10, limp was not noticeable and animal appeared strong and healthy. Sept. 5, 1916, Rhesus No. 51, control, exhibited general tremors and marked muscular weakness. No definite paralysis. Died Sept. 8, 1916. Congestion of the pia and swelling and redden- ing of gray matter of cord. The virus of this monkey subsequently produced typical flaccid paralysis. : Whether or not Rhesus No. 50 really had poliomyelitis, it is difficult to judge. He did not at any time present frank paralysis and his rather rapid recovery is suspicious. This animal was one of whose past history we knew nothing. Experiment 11.— Sept. 21, 1916. Rhesus No. 27, 74 c.c. intracerebrally and 2 c.c. perisciatic, of 10 per cent. virus, III. gen. Rhesus No. 26, control, 14 c.c. intracerebrally, same virus. Sept. 28, 1916. Rhesus No. 27, weakness of left leg; 21% c.c. serum No. 102, intraspinally. Rhesus No. 26, control, paralysis left and weakness right leg. Sept. 29, 1916. Rhesus No. 27, paralysis both legs, weakness left arm; 27% c.c. serum No. 102, intraspinally. Rhesus No. 26, paralysis both legs, left arm, weakness right arm; difficulty in breathing. Sept. 30, 1916. Rhesus No. 27, complete paralysis of limbs and diaphragmatic breathing. Died. : Rhesus No. 26, respiratory failure. Died. The incubation period in both of the above animals was eight days and duration of illness three days. Experiment 11]. — Oct. 2, 1916. Rhesus No. 36, V4 c.c., 10 per cent. virus, IV. gen, intracerebrally. Rhesus No. 37, control, 7% c.c. same suspension, intracerebrally. Oct. 7, 1916. Rhesus No. 36, apparently normal; 3 c.c. serum No. 102, intraspinally. Rhesus No. 37 well. Oct. 8, 1916. Rhesus No. 36 well; 3 c.c. serum No. 102. Rhesus No. 370. XK. Oct. 9, 1916. Rhesus No. 36, paralysis both legs, weakness left arm; 2% c.c. serum No. 102. Rhesus No. 37, control, paralysis left leg, weakness right leg. 283 Oct. 10, 1916. Rhesus No. 36, complete paralysis both arms and legs; breathing with difficulty; no serum, condition bad. Rhesus No. 37, paralysis both legs, weakness left arm. Does not appear as ‘sick as No. 36. : Oct. 12, 1916. Rhesus No. 36 died, respiratory paralysis. Rhesus No. 37, paralysis both legs, weakness left arm. Cessation of progress of paralysis. Nov. 29, 1916. Rhesus No. 37 alive. Permanent paralysis in legs. Left arm O. K. In the above experiment, Rhesus No. 36 received serum treatment on the 5th day after injection of virus and two days before the onset of paralysis. Rhesus No. 37 control, exhibited paralysis on the same day as No. 36, an incubation of 7 days. The serum treatment apparently had no influence on the incubation period. Furthermore, No. 36, despite three treatments, suffered a rapidly spreading fatal form of the disease, whereas No. 37, control, survived the same injection, but with residual paralysis. Experiment IV .— Oct. 13, 1916. Rhesus No. 43, 15 c.c. 10 per cent. gen. V. virus, intracerebrally. Rhesus No. 42, control, very large animal, 1 c.c. intracerebrally and 5 c.c. intraperitoneally of same virus. Oct. 18, 1916. Rhesus No. 43 received intraspinally 3 c.c. serum No. 102. Oct. 21, 214 c.c. serum No. 98. Oct. 22, 2 c.c. serum No. 98. No signs of disease during this period.. Rhesus No. 42, control, pre- sented no symptoms. Oct. 23, 1916. Rhesus No. 43, left leg paralyzed and weakness in right leg; 2 c.c. serum No. 98, given intraspinally. Rhesus No. 42 shows no symptoms. Oct. 24, 1916. Rhesus No. 43, paralysis progressing; 274 c.c. serum No. 102 administered. Rhesus No. 42 apparently well. Oct. 25, 1916. Rhesus No. 43, paralysis involving both arms and legs; 3 c.c. serum No. 102 given. Rhesus No. 42, control, shows weakness in left leg. Oct. 27, 1916. Rhesus No. 43 died of respiratory paralysis. Rhesus No. 42 presents involvement of both legs and weakness of left arm. Oct. 31, 1916. Rhesus No. 42 died of respiratory paralysis. In the above experiment, the serum-treated animal began to receive intraspinal injections of serum on the 5th day after the injection of the virus and five days prior to the appearance of symptoms in the same animal, and 7 days before the control animal exhibited muscular weakness. Fur- thermore, the control animal had several times the dose of virus received by the test animal. The progress of the disease was more rapid in the serum treated animal, which terminated on the Sth day of the disease, than in the control animal, which died on the 7th day of the disease. Experiment V.— Nov. 2, 1916. Rhesus No. 52, 745 c.c. of 10 per cent. VI. gen. virus, intracerebrally. Oct. 31, 1916. Rhesus No. S, large animal, control, 74 c.c. intra- cerebrally and 5 c.c. intraperitoneally, of 10 per cent. VI. gen. virus used on No. 52. 284 Nov. 8, 1916. Rhesus No. 52, apparently normal, received 24 c.c. serum No. 102 intraspinally. Rhesus No. S, control, showed paralysis left arm. Nov. 9, 1916. Rhesus No. 52, paralysis of left leg; 214 c.c. serum No. 102. Rhesus No. S, paralysis of all limbs and respiratory paralysis. Died. Nov. 10, 1916. Rhesus No. 52, paralysis progressing; 2% c.c. serum No. 102. Nov. 11, 1916. Rhesus No. 52, paralysis of both legs, left arm; 2 c.c. serum No. 98 administered. Nov. 13, 1916. Rhesus No. 52, complete paralysis, including muscles of respiration. Died. Though Rhesus No. 52 received a smaller dose of virus and one injec- tion of serum on the sixth day after the inoculation, the incubation period was seven days, whereas in Rhesus No. S, with larger dosage and no serum therapy, the incubation was nine days. This animal, however, suffered a fulminating type of disease, dying on the second day after the appearance of symptoms. This was probably due to the early involvement of muscles of respiration. The serum treated animal died on the fifth day of the disease. Experiment VI— Nov. 10, 1916. Mangabey No. 53, 14 c.c. 5 per cent. VII. gen. virus, intracerebrally. Mangabey No. 54, control, 1=2 cc. 5 per cent. same virus intracerebrally. Nov. 15, 1916. Mangabey No. 53 appears well; 3 c.c. serum No. 102 intraspinally. Nov. 16, 1916. Mangabey No. 53, 3 c.c. serum No. 102; appears normal. Nov. 17,1916. Mangabey No. 53, paralysis of left leg; no serum. Nov. 18, 1916. Mangabey No. 53, paralysis progressing ; 215 c.c. serum No. 98. Mangabey No. 54, weakness left leg. Nov. 19, 1916. Mangabey No. 53, paralysis both legs and left arm; 2 c.c. serum No. 98 administered. Mangabey No. 54, marked weakness in left leg and slight weakness in right leg; progress of paralysis slow. Nov. 20, 1916. Mangabey No. 53 lies prone, does not stir body, moves right arm weakly; tremor of head. Mangabey No. 54, con- dition about the same. Nov. 22, 1916. Mangabey No. 53, complete paralysis; died. Mangabey No. 54, weakness in legs more marked. Nov. 25, 1916. Mangabey No. 54, progress of involvement slow ; shows slight weakness of left arm; tremor of head. Nov. 27, 1916. Mangabey No. 54 shows signs of improvement; left arm apparently stronger, as is also the right leg. Dec. 1, 1916. Mangabey No. 54, improvement marked; feeds well; can sit up without great difficulty ; will probably recover. In the foregoing experiment, the test animal received serum treatment on the fifth day after the injection of virus and two days before symptoms of the disease appeared in an incubation of seven days. The disease ran 285 a progressive fatal course despite four injections of serum. The control animal showed evidence of paralysis on the eighth day after infection, with slowly progressing symptoms and with subsequent improvement. This animal is alive at this writing. Summary. The summary of the results of the foregoing experiments is as follows: Five of the six serum treated animals died, a mortality of 83 per cent. Four of the six control animals died, a mortality of 66 per cent. Of the four animals that received intraspinal serum therapy before the appearance of paralysis, one received 1 treatment, two 2 treatments and one 5 treatments in the pre-paralytic stage. In one of these the incuba- tion period was the same as in the control animal. In the remaining three, the incubation was shorter by one to two days than in the control animals. The duration of the disease in the serum treated animals was somewhat shorter than in the controls, varying from two to six days, whereas in the latter the acute progressive stage was from three to eight days, indicating a greater rapidity in the spread of the disease in the central nervous system. The number of serum administrations varied from two to eight, depending upon the condition of the animal. They were discontinued when the animal exhibited distinct signs of improvement, or when the paralysis had progressed to respiratory difficulty. Discussion. Experimental poliomyelitis is several times more fatal a disease than human poliomyelitis, and perhaps it is rather severe on the clinical use of unknown ‘immune ”’ serum to compare it with experimental use of a like serum in monkey poliomyelitis. However, that seems to be the only method known at the present time of gaining any correct idea of the value of this method of treatment. An effort was made in the foregoing experiments to parallel clinical conditions. Two of the animals were injected with serum on the first day of the appearance of paralysis and four from five to six days after date of infection, but in the pre-paralytic stage. The test animals were controlled by six animals that received no serum therapy. : Comparison of effects of the disease in the serum treated animals as against the effects observed in the control animals, would incline one to the inference that, at least in the experimental disease, intraspinal injections of serum are not only of no value, but also that there may be in them an element of harm. The mechanism producing the untoward effects has not been demon- strated, but it may consist in the exaggeration of the pathological process already existing by the introduction into the subdural space of a foreign substance. Marked meningeal symptoms have been observed following the introduction of serum, both in the experimental and human disease. In some instances the spinal fluids obtained after the injection of serum have 286 shown distinct evidence of accentuated inflammatory reaction, as indicated by increased morbidity, due to increase of cellular elements; increase in the content of albumin and globulin. That this meningeal reaction may have a deliteiions influence on the already existing pathologic process in the cord and brain proper is not without plausibility. Careful comparative study of the nervous tissues of the serum treated and the control animals may indicate whether or not this is the true explanation. In the minds of the general public and of most physicians, there exists a close analogy between the use of serum in epidemic meningitis and in poliomyelitis, and its success in the former has influenced them to have faith in the success of the latter. The pathology of the two conditions, however, is quite different. In acute purulent meningitis the process is limited almost entirely to the meninges, the brain and cord substance being little if at all involved, though there may be some secondary congestions. In poliomyelitis the pathological picture is reversed. Here the brain and cord substance is mainly involved, whereas the inflammation in the meninges is entirely secondary. Injecting a foreign substance into the slightly in- flamed meninges sets up in most cases an acute aseptic meningitis, as is shown by changes in the spinal fluid, and clinically, by increased tempera- ture, rigidity of the neck and other signs of meningeal irritation. It is reasonable that this increased inflammatory reaction should tend to accentu- ate the inflammatory changes existing in the subjacent substance of the brain and cord. This is contrary to the commonly accepted idea that the first indication in the treatment of an inflammation is rest. And that this reaction may be harmful is borne out by the results of animal experimenta- tion. In meningitis, on the other hand, the injection of serum into actively inflamed meninges is not followed by an increase in the inflammatory reaction, as is evidenced by the clearing up of the fluid and the amelioration of the clinical symptoms in favorable cases. It would seem, therefore, that from this point of view the action of the serum may even be distinctly harmful. As to its specific neutralizing power, this would have to be exerted very speedily, since the damage is so often done within 48 or 72 hours after the onset of symptoms. SUMMARY OF EXPERIMENTS ON INTRASPINAL TREATMENT WITH UNKNOWN “IMMUNE” SERUM. In these cases, history of disease by patient not verified by tests for antibodies. SERUM INJECTION VIRUS INJECTED. INTRASPINOUSLY. PARALYSIS. Duration Incuba- of No. Gen. Amount. Site. Date. Date. Amount, Sogsce: Date. tion. Disease. Character, Extent. Outcome o. 50 Rhesus II %c.c. 10% Brain Sept. 6,1916 3}4c.c. 102 Sept. 6,1916 5 days 2 days Slight weakness in left leg. Alive and 2 c.c. 10% Sciatic Sept. 1, 1916 Sept. 7,1916 3}5c.c. 102 well 10 c.c. 10%, Peritoneum : 51 Rhesus II Y4c.c. 10% Brain Sept. 1,:1006 ds he eno Tiana . Sept. 5,1916 4days 3 days General muscular weakness, Maran- Died Control tic type. Sept. 8, 1916 27 Rhesus III Y c.c. 10% Brain 1 Sept. 28, 1916 214 c.c. 102 Sept. 28,1916 8 days 3 days Rapid progressive paralysis left leg, Died 2 c.c. 10% Sciatic [Sept. 21, 1916 Sept. 29,1916 2l4c.c. 102 right leg, left arm and right arm Sept. 30,1916 Respiratory failure. 26 Rhesus IIT Y%c.c. 10% Brain Sept: 21, 1916: Lu co vei sae Bad . Sept. 28,1916 8 days 3 days Rapid progressive paralysis, left leg, Died Control right leg, left arm, right arm. Sept. 30,1916 Respiratory failure. 36 Mac IV Y%c.c. 10% Brain Oct. 2,1916 Oct. .7,1916. 3cc 102 Oct. 9,1916 7 days 4 days Rapid progressive paralysis beginning Died Rhesus Oct. 8,1916 3cc 102 with left leg, right leg, left arm, Oct. 12 Oct. 9,1916 2Y%c.c. 102 right arm. Respiratory paralysis. 37 Rhesus IV ¥%c.c. 10% Brain Oct, 2, 1000s vet a ve divte . Oct. 9,1916 7 days 4days Pros. flaccid paralysis beginning leftAlive; has Control acute leg, right leg, left arm, then re- diplegia gression. 43 Rhesus V Y%c.c. 10% Brain Oct. 13, 1916 Oct. 18 3c.c. 102 Oct. 23,1916 10days 5days Progressive flaccid paralysis begin- Died Oct. 19 2%ecc. 102 ning with left leg, then right leg,Oct. 27, 1916 Oct. 20 3cc. 102 then left arm, then right arm. Oct. 21 2Y cc 98 Respiratory failure. Oct. 22 2 c.c 98 Oct. 23 2c. 98 Oct. 24 21% c.c. 102 Oct. 25 Scc 102 42 Giant V 1c.c. 10% Brain 10s 13, 100610 Eanes ... Oct. 25,1916 12 days 7 days Progressive spinal paralysis, begin- Died Rhesus 5 c.c. 10% Peritoneum ning with left leg, then right leg; Oct. 31, 1916 Control simultaneously in both arms. Repsiratory failure. 52 Rhesus VI %c.c. 10% Brain Nov. 2,1916 Nov. 8 23 cc. 102 Nov.9,1916 7 days 5days Progressive spinal, beginning with Died Nov. 9 2% cc. 102 left leg, right leg, left arm, right Nov. 13, 1916 Nov. 10 24 cc. 102 arm. Nov. 11 2 cc. 98 S Rhesus VI Y%c.c. 10% Brain Nov. 2,1916 ...ccnnvvvus cavens . Nov. 8,1916 9days 2days Rapid progressive spinal, beginning Died (Large) 5 c.c. 10% Intraperi- h left arm, then right, then Nov. 9, 1916 Control toneally Midas failure. 53 Mangabey VII 4 c.c. 5% Brain Nov. 10, 1916 Nov. 15 3c.c. 102 Nov. 17,1916 7 days 6 days Progressive spinal paralysis, begin- Died Nov. 16 3 cc. 102 ning with right leg, left leg, left - Nov. 22, 1916 Nov. 18 2% c.c 98 arm, right arm. Respiratory Nov. 19 2ce 98 failure. 54 Mangabey VII ¥% cc. 59% Brain Noy: 10,3986. «ous taiiemsn. Wannas .. Nov. 18,1916 8days 8 days Progressive spinal paralysis, begin- Alive and Control ning with left leg, weakness right leg and left arm, slight weakness in right arm. Improving 482 288 2. ORTHOPEDIC TREATMENT. In the orthopedic treatment of poliomyelitis at the Willard Parker Hospital it was found best to allow all cases to remain undisturbed in bed during the presence of acute symptoms, as fever, pain, etc. At the end of this time, usually about one week, each case was carefully examined by the attending orthopedic surgeon to determine the extent of the paralysis and to decide upon the best means of supporting the involved muscles, to relieve strain, and to prevent deformity. For cases with involvement of neck and back muscles and those with the more marked meningeal symptoms, a frame bent to coincide with the contour of the back was found most effectual for relieving the strain on the muscles and also alleviating the pain, which was often very severe. For involvement of neck muscles, a light plaster collar with sometimes a hood attachment was applied. Plaster casts and moulded plaster splints were applied to paralyzed extremities. All forms of support were removed at frequent intervals to enable the patient to practice voluntary movements, to preserve joints, and to guard against decubitus, which was apt to occur very quickly in the more severely ill cases. It was interesting to note that many very fretful children immediately became quiet and contented when proper support was supplied. During the fifth week all patients with paralysis still present were care- fully examined with a view of determining the best form of future treat- ment. We attempted to classify them as follows: Those patients with extensive paralysis who are unable to hold the body erect and for whom any immediate form of ambu- story: treatment IS IMpPOssible: cnivat ivi bv rat shinai « 6 cases Patients with slight paralysis or weakness in whose muscles power isi rapidiy: retnrning. oul akin rebels niaisie d 1443 cases Patients whose paralyzed muscles apparently do not exhibit any sign of returning power and the paralysis might be consid- ered more OF less pernunent ous, Jiro wdd or viedo iss 9 cases Patients with marked paralysis but with some returning power, in which recovery would probably take months or a year OREO. 2 1 Lo a al a I Sat el i Seid A ly 249 cases Patients in group one were discharged with plaster supports. It was recommended that these patients receive continued hospital care if possible. Group two patients were discharged with plaster splints if necessary and were referred to a neighboring clinic for continued supervision. Patients in group three were carefully fitted with braces with lock joints, etc., and crutches if necessary. Those in group four were fitted with a less expensive but suitable type of brace, as it was thought probable that the brace would be unneces- sary after a few months. 289 Children under one year of age were discharged with light plaster sup- ports. A few adults who might be classified in group one were equipped with braces and crutches to enable them to stand up and perhaps take a few steps, but more especially to obviate possible domestic difficulties and to prevent, if possible, that condition of mind so frequent in those hopelessly bedridden. The paralysis about the shoulder seemed slowest to improve. For these cases a brace which would hold the arm at right angles to the body was prescribed. A short leg brace with a stop to prevent foot-drop was used in cases of paralysis of the anterior tibial group, or the stop was reversed when the posterior tibial group was involved, or a double stop when both groups were involved, a straight brace extending up the thigh, allowing no motion at the knee, was used when the flexors or extensors of the leg are involved. For cases in group three this brace, with a movable joint which locks in extension, was used. Those cases with involvement of the rotators of the thigh, and muscles about hip-joint, were equipped with a brace extending up to the pelvis and having a pelvic band. The motion in this brace at the hip is adjusted to the requirements of the case. If both lowers are involved a double brace may be used. These cases were also equipped with crutches if necessary. It has been observed in numerous instances that the paralysis has greatly improved as soon as the patient has gotten up and about with the brace. This is well shown by the large numbers of cases in which it has been possible to cut down the brace, lessening the number of muscles sup- ported by it or, as in many cases, to entirely dispense with the brace. We believe that the effort to maintain equilibrium and to get about supplies a stimulus such as no other method of treatment can supply to the nerve centers, nerves, and muscles, and possibly facilitate the opening of new paths for the transference of motor and trophic impulses to the muscles. The patients to whom we have supplied braces are being visited at their homes, to make sure that the brace is being properly worn and that instructions as to bathing, exercise and massage are properly carried out. CHAPTER XIII. Prophylaxis. Poliomyelitis being an acute infectious disease, it follows as a logical consequence that the same sanitary measures must be employed, and the same regulations enforced, for the prevention of its spread as for the pre- vention of any other acute infectious or communicable disease, isolation, disinfection, etc. It is obvious from what is known of the nature of the infection, that segregation and other similar measures approaching complete control, must be impracticable, as segregation to be effective in poliomyelitis must include not only paralytic, but also non-paralytic or abortive cases, and the healthy carriers of the virus; nor is there any specific antitoxin or protective vaccine against the disease upon which we can rely for the im- munization of exposed susceptibles. Under these circumstances, as soon as the Department of Health real- ized that it was facing an outbreak of poliomyelitis, it took steps to pro- vide for the enforcement of the necessary general sanitary measures for the prevention of its spread. The first step toward the attainment of this object was, primarily, to enlist the co-operation of the medical profession in the work that had to be performed ; secondly, to instruct the public as to the reasons for the necessity of its performance. For this purpose, in addition to the exaction of the usual requirement that all recognized and suspected cases of the disease be promptly reported, there was issued, early in July, a circular of “ Infor- mation for Physicians Regarding Poliomyelitis (Infantile Paralysis),” stat- ing what was known concerning the causes, modes of infection, transmis- sion and symptoms of the malady, and giving directions as to the general care of the patients. Later, there was issued another circular of “ Informa- tion for the Public Regarding Infantile Paralysis (Poliomyelitis),” describ- ing in simple, non-technical language the early symptoms of the disease and- its communicability through the discharges of the nose, throat and bowels of those ill with the disease to well persons, and laying especial stress upon its transmissibility by means of non-paralytic cases and healthy persons from sick persons with whom they were associated. Instructions were also given how to guard against the disease, what to do in cases of sickness and what the Health Department would do. A copy of these circulars and other special information regarding procedure in poliomyelitis regulations governing quarantine, removal, care and treatment of persons suffering from the disease, etc., issued by the Department of Health, will be found in the appendix. These procedures for the prevention of the spread of infection were strictly enforced and the physicians of the city, appreciating the situation, willingly lent their aid toward the support of the health authorities. 291 To cite an instance of this support in the matter of reporting cases: From August 5th to December 16th, 1916, inclusive, a record was kept by the Department of all the field assignments given inspectors for investiga- tion of reports from all sources, of poliomyelitis or suspected poliomyelitis cases, together with the number found by diagnosticians to be true cases. This record shows that as the epidemic advanced the percentage of true poliomyelitis cases to assignments perceptibly diminished; in other words, that an increasing number of suspected cases were reported by physicians as their knowledge and interest grew with the extent of the epidemic. The figures given below include all cases reported from August 5th to December 16th, with the exception of one week in August, for which the data are not available: Percentage of True Poliomyelitis to Inspections. Assignments. True Cases. Percentage. AUGUSE -CELOM FthH) hice viii vo wiisicins sale rain ine 5,208 2.975 57 SEPtEMDer: ov ianis hs snnsinnds sie ss sales esses vonie 2,382 1,345 .56 OCLODET: vous vininiin snivins vs s damian us bois 529 248 .46 November is... Jo ado ss SB matsates Svs oie 136 46 33 DEcemBEE ov iT ahi isis ian athin Bdrin aia 4 0 late 50 18 +30 Toal oon hn lh bie mands unis 8,305 4,632 $55 During the epidemic, including a period of sixteen weeks, whenever a case of poliomyelitis was reported a careful survey was made of every stable within a radius of four blocks. In these stables, when an insanitary condition was found, frequent reinspections were made until the nuisances were abated. Thus a total number of 10,996 inspections were made in 5,142 stables; unclean stalls, runways, floors, ceilings and walls were carefully inspected, manure removed, yards cleaned, etc. The street car lines were inspected and orders issued to have the cars cleansed carefully and thoroughly at least once a day and maintained in a cleanly condition at all times. The food stores in the city and the various places where food is kept or handled, were carefully inspected and special provision was made to insure the sanitary condition of all foods and drinks distributed during the epidemic. As a result of this active and vigorous work for health and cleanliness, on the part of the health authorities, and especially because of the campaign of publicity and education conducted through the Department’s Bureau of Public Health Education, the whole city was aroused to interested participa- tion in the work of sanitation. It was observed by everyone acquainted with ordinary conditions that the city was never before so clean; that tene- ment houses were never so clean; parents were never so careful about their children, food was never so generally kept covered and kept clean, and 292 sound medical advice was never so eagerly sought or so well followed. Moreover, sanitary regulations were never so easily enforced as during the epidemic. The violations that occurred were due mainly to oversight and not to indifference or wilful disobedience. Nor were other organizations behindhand in furthering the work of sanitation. Invaluable aid was rendered by practically all the other municipal departments, and by many private associations. The streets were flushed daily, tenement houses were inspected and violations of the law directed and remedied. Hospital care was provided for thousands of patients—besides the large number of cases treated in the Department of Health hospitals, many additional cases were admitted to 28 or 30 other hospitals in the city. Automobiles and ambulances were turned over to the Health Depart- ment to use for this work. Orders for large amounts of printing were hur- ried through. Funds were provided and additional physicians, laboratory workers, nurses, domestics and others were employed. A host of volunteers aided in the distribution of health leaflets; and press and pulpit zealously joined in preaching the propaganda of prophylaxis. Altogether the com- munity set an example of co-operation for health and civic betterment which deserves the highest commendation. This work of co-operative sanitation, instigated by the stimulus of a dreaded disaster, not only succeeded in checking the visible calamity, but it produced an unseen and unexpected result which was even more remarkable in its effects. Notwithstanding the prevalence of the epidemic of polio- myelitis—a disease which fatally affects young children in particular, 80 per cent. of those attacked dying from it in the first five years of life—both the mfant mortality and the general death rates of the city were as low or lower, throughout the summer of 191€, than they were during the same period of 1915, when there was no epidemic to contend with. The table (p. 295) giving the official mortality statistics for the City of New York, for 1915 and 1916, demonstrates these remarkable results in figures that cannot be controverted. Commentary is unnecessary with such facts as these to prove the efficacy of co-operative sanitation in public health work. Unfortunate as the recent epidemic undoubtedly was, and in some respects unproductive from an epidemiological point of view, this disastrous visitation may yet turn out to have been a blessing in disguise, if it fixes indelibly in our minds one obvious and incontestable truth—that the control not only of polio- myelitis, but of all preventable diseases, does not depend upon the mysterious power of any supernatural agency, but that the remedy lies largely within ourselves. “Our remedies oft in ourselves do lie, Which we ascribe to heaven: the fated sky Gives us free scope; only doth backward pull Our slow designs, when we ourselves are dull.” 293 APPENDIX. Names of Members of Committees in Connection with Poliomyelitis Epidemic. Committee on Infantile Paralysis—Advisory Council. Dr. Louis C. Ager, Chairman.* Dr. Simon Flexner.* Dr. Elias H. Bartley. Dr. Royal S. Haynes. Dr. Robert O. Brockway. Dr. Henry Koplik. Dr. Eugene S. Dalton. Dr. Howard Mason. Dr. Thurston H. Dexter. Dr. Herman Schwarz. * Dr. A. H. Doty. Dr. J. T. Simmonson. Dr. George Draper. Dr. Rudolph F. Rabe. Dr, 8. J. Baker. Dr. J. S. Billings. ; Dr. S. BR. Blatteis. Representaiives Dr. Charles F. Bolduan.* oF the Dr. George L. Nicholas. Department of Health. Dr. W. 1 Dark. Dr. B. S.. Waters. Dr. R. J. Wilson. Mayor's Committee on the Epidemic of Poliomyelitis (to Act as His Advisers During the Epidemic). Dr. E. H. Bartley. Dr. Henry Koplik Dr. John W. Brannan. Dr. Samuel Lambert Dr. Leland E. Cofer. Dr. C. H. Lavinder Dr. H. B. Delatour. Dr. Leon Louria Dr..A.-H. Doty Dr. William H. Park Dr. George Draper Dr. Antonio Stella . Dr. Simon Flexner. Pr: 7.-M. Van Cott Dr. S. S. Goldwater. Dr. Philip Van Ingen Dr. Walter B. James Committee on Research on Poliomyelitis. Dr. H. 1. Amoss. Dr. Josephine B. Neal. Dr. George Draper. Dr. William H. Park. Dr. W. H. Frost. Dr. Hans Zinsser. Dr. C. H. Lavinder. * These had been members of the Collective Investigation Committee which studied the 1907 epidemic. 294 Orthopedists Connected With Department of Health Hospitals. Dr. A H.Cilley.......... Riverside Hospital. Dri]. J. Notts. 5.000 Willard Parker Hospital. Dr. Henry Ling Taylor. . Queensboro Hospital and Swinburne Island. Dr. D. Truslow........5. Kingston Avenue Hospital. Committee on Permanent Relief and Follow-up Care. Miss Bessie Amerman, Henry Street Settlement. Dr. Oliver Bartine, Hospital for Ruptured and Crippled. Dr. Henry W. Frauenthal, Dispensary and Hospital for Joint Diseases. Miss Jessie M. Hixon, Association for Improving the Condition of the Poor, Brooklyn. Dr. John R. Howard, Jr., N. Y. Orthopedic Dispensary and Hospital. Miss Bessie LeLacheur, Association for Improving the Condition of the Poor, Manhattan. : Dr. Thomas J. Riley, Brooklyn Bureau of Charities. Dr. Jacques C. Rushmore, Long Island College Hospital. Dr. Reginald H. Sayre, Attending Orthopedist, Bellevue Hospital. Dr. J. D. Steinhardt, Bronx Hospital and Dispensary. Dr. Walter Truslow, Kingston Avenue Hospital. Dr. Morris D. Waldman, United Hebrew Charities. Dr. Donald E. Baxter, Director of Committee. Committee on House to House Visits. ORGANIZATIONS REPRESENTED. Associated Charities of Flushing. Brooklyn Association for Improving the Condition of the Poor. Brooklyn Bureau of Charities. Charity Organization Society of New York. Henry Street Settlement. Metropolitan Life Insurance Company. New York Association for Improving the Condition of the Poor. United Hebrew Charities of New York. United Jewish Aid Society of Brooklyn. University Settlement Society. 295 Death Rates by Months at All Ages and Under One Year of Age. City of New York—1915 and 1916. 1915. 1916. Death Rate Death Rate Rate Under Rate Under Per Deaths 1 Year Per Deaths 1 Year Deaths. 1000 Under of Age 1000 Under of Age All Popula- 1 Year Per 1000 All Popula- 1 Year Per 1000 Causes. tion. of Age. Births. Causes. tion. of Age. Births. January.... 6,872 14.81 1,160 938 7,966. 1675 1,106 98.5 February... 6,126 14.61 1,008 89.9 0,723 15.11 1,054 91.8 March... .... 7,462 16.08 1,231 93.4 7,071 14.88 1,126 90.3 Apal.: 7,681 17.10 1,239 102.0 6,791 14.75 1,082 97.0 May 6,625 14.27 1,191 107.4 6,601 14.00 1,086 96.1 June: uo. 5,862 13.04 1,082 88.1 5,723 12.43 881 78.8 July... 0.03 5,818 12.54 1,201 105.6 6,209 13.05 1,072 96.3 August, .... 6011 12.95 1,598 130.9 7,011 14.75 1,614 131.1 September. . 5,543 12.34 1,326 114.2 5,578 12.12 1,098 99.8 Qctober.....: 5,582 12.03 1,032 91.3 5,605 11.78 889 75.8 November. . 5,562 12.38 855 78.6 5,792 12.38 887 80.4 December... 7,049 15.19 973 81.3 6,665 14.01 923 79.1 Year... 76,193 13.93 13,866 98.2 77,801 13.88 12,818 93.1 SoME REFERENCES CONSULTED. V. Heine: Beobachtungen ueber Laechmungszustaende der unteren Extremitaete und derer Behandlung. Stuttgart, 1840. Spinale Kinder- laehmung, 1860. M. P. Jacobi: Pathology of Infantile Paralysis. Obstetrics, Vol. 7, p. 1, 1874. O. Medin: Kliniske og Epidemioliske Undersoeglser over der Akute Poliomyelit i Norge. Vidensk. Selsk. Skr. Christiana, 1909. Ed. Mueller: Die Spinale Kinderlaehmung, Berlin, 1910. Wickman: Acute Poliomyelitis (Heine-Medin’s Disease). Tr. Ma- loney. Jour. of Nerv. and Ment. Dis., Monograph Series No. 15, 1913. Warner: Die Heine-Medin Krankheit, Leipzig, Diss. Halle, 1913. Collective Investigation Committee: Report on the New York Epi- demic of 1917. Jour. of Nerv. and Ment. Dis., Monograph Series No. 6, 1910. Frost: Hyg. Lab. Bull. No. 90, Washington, D C. Frauenthal & Manning: A Manual of Infantile Paralysis, 1914. Lovett: The Treatment of Infantile Paralysis, Philadelphia, 1916. Harbitz & Scheel: Pathologish-anatomische Untersuchungen ueber Akute Poliomyelitis and Verwandter Krankheiten von der Epidemien in Norwegen, 1903-1906. Vidensk. Selsk. Skr. Christiana, 1907. Peabody, Draper and Dochez: Rockefeller Institute, New York, 1912. Landsteiner and Popper: Ztschr. {f. Immunitaetsforsch. 11, 1909. Leiner and Weisner: Wien, Klin. Wochschr. XXII, 1909. Landsteiner and Levaditi: Compt. Rend. Soc. Biol.,, LXII and LXVII. Flexner and Lewis: Jour. Amer. Med. Assoc., 1909 ; also 1910 and 1913. Flexner and Noguchi: Jour. Exp. Med., XVIII, 1913 and 1914. Netter: Bull. del’Acad. de Med., LXVI, 1914. Rosenow, Towne and Wheeler: Jour. Amer. Med. Assoc., LXVII, 1916. American Journal of 296 Regulations, Leaflets, Circulars and Bulletins Issued by the Department of Health. (REGULATIONS.) Regulation 1. Incubation period. —The incubation period of the dis- ease and the quarantine period of children under sixteen (16) years of age who have been, but no longer are, exposed to infection shall be fourteen (14) days. Regulation 2. Quarantine—In all families where a case of Poliomyeli- tis has occurred, all the children under sixteen (16) years (except those who have had the disease), shall be quarantined in the home until two (2) weeks after the termination of the case by death, removal, or recovery. The patient whether at home or in a hospital shall be quarantined for six (6) weeks from the date of the onset of the disease. No case in a hospital shall be returned home until the quarantine is ended. Regulation 3. Placards—All premises where a case of Poliomyelitis occurs shall be placarded; the only exceptions being hotels and boarding houses, which shall not be placarded provided the patient is at once re- moved to the hospital, the room or rooms occupied by the patient immedi- ately renovated in accordance with the requirements of the Bureau of Pre- ventable Diseases, and no quarantined children remain on the premises. In private houses, one placard shall be affixed to the door entering the room the patient occupies. In apartment and tenement houses, one placard shall be affixed to the door of the apartment occupied by the patient. All such placards shall be dated and initialed by the representative of the Depart- ment who affixes the placards in accordance with the provisions of this Regulation and shall remain so affixed until the quarantine is terminated and the renovation completed. (As amended by the Board of Health, Sep- tember 26, 1916.) Regulation 4. Removal to Hospital —No case shall be left at home unless the following conditions are complied with: a. There must be a physician in daily attendance. b. The patient must have a special attendant who must obey the quarantine Regulations and must not do any housework, market- ing, or perform any household duties for other members of the family. He or she may, however, leave the house, provided the neces- sary precautions as to personal disinfection, etc., are observed, and contact with all children should be avoided. ¢. The patient and the attendant must have a room or rooms separate from the rooms of others in the family. d. All the windows of this room must be screened and all flies in the room killed. e. The family must have a separate toilet for its exclusive use. f. Quarantine Regulations must be strictly observed by the patient and the other children of the family, if any. When the disease occurs in the premises of families of food handlers, the employment of such person or persons at this occupation is forbidden, unless they 297 occupy entirely separate apartments for a period of two weeks after the removal, recovery, or death of the patient. g. The personal and bed linen of the patient must be properly disinfected and, after removal, recovery or death of the patient, com- plete renovation of the room or rooms occupied by the patient and atendant shall be required. Regulation 5. Visitors to Hospitals—Each case may be visited twice during its stay in the hospital, by a parent or guardian. If the child is criti- cally ill, the guardian or parent will be notified and will be permitted to visit daily, while child is dangerously ill. Information relative to condition is given out at the Information Desk in each hospital, or by telephone in response to telephone inquiry from the parent or guardian. Regulation 6. Certificates for children leaving the ciiy.—The Depart- ment of Health of the City of New York does not require certificates of anyone leaving or entering the City. It issues certificates only as a con- venience and aid to persons leaving the City. Nome are issued to persons passing through the City. Such certificates state that the persons or family therein named have not resided in a house where a case of Poliomyelitis has occurred. The applicant must sign a request for the certificate. They are refused to per- sons who live in a house where a case of Infantile Paralysis has occurred, or who present symptoms of the said disease. The certificates are good only until midnight of the following day, except when issued on a Saturday or on the day preceding a holiday, when they are good until midnight of the second following day. Regulation 7. Return of cases of Poliomyelitis to New York City.— Cases of Poliomyelitis occurring in residents of New York City who are temporarily residing outside the City, and developing within two (2) weeks of the time of leaving the City, shall be permitted to return, provided: (a) a private conveyance (private car, private automobile, carriage or ambulance) is used, and (b) the patient goes direct to a hospital authorized by the Department of Health to care for cases of Poliomyelitis. Cases in which the onset of the disease occurs two weeks or more after leaving the City, may not return to New York City until eight weeks from the date of onset of the disease. But in special cases, where proper medi- cal, surgical and nursing care is not obtainable, patients may be brought back to the City in a private conveyance, provided they go directly to a private hospital authorized by the Department of Health to receive cases of Poliomyelitis. Regulation 8. Return of children who have been exposed to Polio- myelitis to New York City—Children under sixteen (16) outside of New York City who have been exposed to infection with Poliomyelitis within two weeks, may return to the City under the following conditions: a. They must come by private conveyance and must go direct to their homes. 298 b. Advance notice must be sent, and authorization obtained, by telephone, by the local Health Officer. Such notice must give the name and age of each child, together with the identified address, including the floor, and the latest date of exposure to infection, and must be followed immediately by a written notice. c. Such children shall be promptly visited at their homes by a representative of the Department of Health and instructed as to nature and duration of quarantine. They must not leave the premises until two weeks have elapsed from the date of last exposure to infec- tion. d. The premises shall not be placarded, but the children shall be visited at regular intervals, and should quarantine be violated the parents or guardians shall be summoned to Court and fined. ( PROCEDURES.) Duties of Inspectors—Cases reported by physicians, nurses, social workers and other citizens shall be visited at once by Inspector, whether such report requests removal of the case to a hospital or not. Attending physicians to the Department of Health hospitals, however, may admit cases direct without Inspectors’ visits. The janitor of the building in which a case of Poliomyelitis occurs, or his or her representative, shall be seen in every instance by the Inspector and notified that he or she will be held personally responsible by the De- partment of Health for failure to report any breach of the quarantine Regu- lations or the removal or defacement of the placards placed on the building. If the Inspector makes or confirms the diagnosis of Poliomyelitis, the Borough Office of the Department shall be notified. Such Borough Office shall, if removal of patient is recommended, summon an ambulance. In every case the Inspector shall leave with the person in charge or control of the patient a hospital admission slip or card, properly and fully filled out and signed. Where a case is permitted to remain at home, the Inspector shall give full instructions to the family. Cases of questionable diagnosis must be seen, at once, in consultation, with the Borough or Chief Diagnostician, and whenever required, a spinal puncture shall be made and a laboratory report submitted by the staff of the Research Laboratory. Cases with positive laboratory findings will be considered as Poliomyelitis, regardless of clinical signs. A full history must be recorded on a special card (Form 316-V) for each assignment covered by Inspectors. Duties of Nurses.—Nurses shall visit every case reported, to instruct the family regarding quarantine, and every other family in the house: a. That there is a case of this disease in the house. b. That the other children of the family in which the disease has occurred shall be quarantined, and that, should they fail to ob- serve quarantine, that fact should be immediately reported to the Department of Health, when steps shall be taken to enforce quaran- tine by a summons to Court. 299 c. Regarding home cleanliness, personal hygiene, and danger of infection by flies, and other general measures which should be taken to prevent infection. d. To report at once to the Department any cases of suspicious illness of children, or any cases of Poliomyelitis, especially if there is no physician in attendance. A current history (Form 304-V) must be kept by the nurse for every case, giving dates of visits, action taken and date and mode of termination. Nurses must see the janitor or his or her representative on first visit and repeat the instructions given by the Inspector. Patients remaining at home, and families with quarantined children, shall be visited daily, or more often if necessary, by a nurse or patrolman for the purpose of ascertaining whether or not the Regulations governing the maintenance of quarantine are being complied with. After removal, recovery, or death of the patient, nurses shall issue renovation notices and make subsequent reinspections until the terms of such notices have been complied with. . Duties of Sanitary Police—Sanitary police officers shall visit quaran- tined premises frequently, daily if necessary, to enforce quarantine of patient and other children in the family and to affix or replace placards. If quarantine Regulations are violated, they are authorized to serve a sum- mons upon the person responsible therefor. Duties of Ambulance Surgeons—All cases ordered removed to the hospital must be removed by the ambulance surgeon without question, with the following exceptions, in each of which the ambulance surgeon must first obtain telephone authorization from the Resident Physician of his hospital, to leave the case at home: a. When removal would endanger life of child (bulbar cases). b. When family physician can show that requirements will be met at once (or within 12 hours). Doubtful and mixed infection cases must be removed by themselves in a separate ambulance. In every case ambulance surgeons must leave a card with parents, giving name and address of hospital to which patient is taken. If inspector has not left admission slip, surgeon must make out same. Persons leaving New York State—Ofhcers of the U. S. Public Health Service, stationed at transportation terminals, require the above certificates before they will permit children under fifteen (15) years of age, resident in New York City, traveling to points outside of the State of New York, to leave the City. The original applicant must again sign the certificate in the presence of the Federal Health Officer. Federal Health Officers do not require certificates of any adults. Persons Going to Points within New York State—Residents of New York City, adults or children, traveling to points within New York State, 300 who present certificates of good health from their family physicians, may also obtain the above certificates from the Department of Health. If no physician’s certificate of good health is presented, applicants will be examined by a physician and their freedom from symptoms of Poliomyelitis certified ; in this case, all children must be brought to the proper office of the Depart- ment. (LEAFLET.) (Issued July 20, 1916.) INFANTILE PARALYSIS. (Poliomyelitis.) INFORMATION FOR THE PusLic. Infantile Paralysis (Poliomyelitis) is a catching disease. How it is spread is not yet definitely known. In most cases the disease is probably taken directly from a sick person, but it may be spread indirectly, through a third person who has been taking care of the patient, or through children who have been living in the same household. The early symptoms are usually fever, weakness, fretfulness or irrita- bility, and vomiting. There may or may not be acute pain at this time. Later, there is pain in the neck, back, arms or legs, with great weakness. If paralysis is to occur, it usually appears from the second to the fifth day after the sickness begins. Many cases do not go on to paralysis. The germ of the disease is present in discharges from the nose, throat and bowels of those ill with infantile paralysis, even in the cases that do not go on to paralysis. It may also be present in the nose and throat of healthy children from the same family. Do not let your children play with children who have just been sick or who have or recently have had colds, summer complaint, etc. For this reason children from a family in which there is a case of infantile paralysis are forbidden to leave their home. If you hear of their doing so, report it at once to the Department of Health. - Persons over 16 years of age, from families where there are cases of poliomyelitis, may continue at work unless their business has to do with the preparation or handling of food or drink for sale. If you hear of a case in your neighborhood and the house is not placarded, notify the Department of Health. How to Guard Against the Disease. In order to prevent the occurrence of this disease, parents shculd observe the following rules: Keep your house or apartment absolutely clean. Go over all woodwork daily with a damp cloth. 301 Sweep floors only after they have been sprinkled with sawdust, old tea-leaves, or bits of newspaper which have been thoroughly dampened. Never allow dry sweeping. Screen your windows against flies, and kill all flies in the house. Do not allow garbage to accumulate, and keep pail closely covered. Do not allow refuse of any kind to remain in your rooms. Kill all forms of vermin, such as bedbugs, roaches and body-lice. Pay special attention to bodily cleanliness. Give the children a bath every day and see that all clothing which comes into contact with the skin is clean. Keep your children by themselves as much as possible. Do not allow them to visit moving picture shows or other places where children may gather. Children should not be kept in the house; they should be out-of-doors as much as possible, but not in active contact with other children of the neighborhood. Do not take them on a street car, unless absolutely neces- sary, or shopping. Do not allow your children to be kissed. It is perfectly safe to let your children go to the parks and playgrounds if only two or three of them play together; they should not play in large groups, and you should not let them come into contact with children from other parts of the city. Remember that children need fresh air in the summer time, and outdoor life is one of the best ways to avoid disease. } If there is a public shower bath in a school in your vicinity, send the older children there every day for a shower bath. This is perfectly safe and will help keep them in good health. Give your children plain, wholesome food, including plenty of milk and vegetables. Keep the milk clean, covered and cold. Do not allow the milk or any other food to be exposed where flies may alight upon it. Wash well all food that is to be eaten raw. In Case of Sickness. Remember that during the hot weather children are apt to have stomach and bowel troubles. If your child is taken sick with loose movements of the bowels, or with vomiting, do not at once fear that it must be infantile paralysis; it may be simply digestive disturbance. Give the child a table- spoonful of castor oil and plenty of cool water to drink, and send for the doctor at once. If you cannot afford a doctor's services, telephone the Department of Health and one will be sent free of charge. 302 If a doctor or nurse from the Department of Health visits your home, give them all the information you can. They are sent to show you how to keep your children well. Do not give your children patent medicines or buy charms of any kind to ward off the disease. The best preventive is cleanliness and strict observ- ance of the rules that have been given. Although there is no specific cure for the disease, much can be done to reduce the amount of crippling caused by the paralysis. It is important to remember that this requires the services of a trained physician and the care of a competent nurse. Unless you can give these to your child, send word at once to the Department of Health, so that the patient may receive proper care in a well-equipped hospital. Of the children cared for in hospitals, only one-quarter as many died as of those treated at home. Give your child a fair chance and let the hospital doctors care for it. What the Health Department Will Do. If a case of infantile paralysis occurs in your home, your doctor must at once notify the Department of Health. An inspector will be sent to investigate. He will paste a sign on the door of your house and apartment warning all people not to enter. This sign must not be removed except by some one sent by the Department of Health. The inspector and nurse will tell you just what to do to protect yourself and the others in the family. Should you want any further information, write or telephone to the BUREAU OF PREVENTABLE DISEASES DEPARTMENT OF Hearth, City or NEw York 139 CENTRE STREET, NEW YORK. (LEAFLET.) (Issued July 20, 1916.) POLIOMYELITIS INFORMATION FOR PHYSICIANS. Early Diagnosis. The attention of physicians is called to the necessity of an early diag- nosis of all cases of poliomyelitis. Early recognition and strict quarantine are the chief weapons against the disease. Reporting of Cases. All suspicious cases must be at once reported to the Department of Health by Telephone, to be followed within twenty-four hours by a written report. The ability of the Department of Health to limit the spread of the infection depends upon the immediate reporting of every suspicious case. 303 Age of Persons Affected. It should be remembered that this disease may occur at all ages, although the great majority of the cases are found in children between the ages of one and five years. Type of Disease. Peabody, Draper and Dochez, of the Rockefeller Institute, give the following classification of the disease: 1. The non-paralytic or so-called abortive cases. 2. The cerebral group, with spastic paralysis. 3. The bulbo-spinal group. Methods of Infection. The experiments of Landsteiner and Popper in Germany ; Kling, Pet- terson and Wernstedt in Sweden, and of Flexner and Noguchi in this country, have proved that the disease is transmitted by the secretions of the nose and mouth, and the bowel discharges of an infected person. The infection is transmitted through the mouth, tonsils and nasal mucous mem- brane. Contacts and Carriers. It must be remembered that while the transmission of the disease from a patient to other members of the same family is not usual, transmission of the virus is common. Experience warrants the assumption that in addition to direct contact, the disease is spread by carriers, usually children, who are themselves immune but who harbor the infective material in their nasal or mouth secretions. Symptoms. Early symptoms to be regarded as suspicious are: Fever, vomiting, slight diarrhcea, listlessness, unusual fretfulness and drowsiness. Later, and more characteristic symptoms, are: The appearance of weakness in any extremity, skin and muscular sensitiveness, spinal pain, especially on flexion, apparent or real rigidity of the neck muscles, Kernig's and Mac- Ewen’s signs. Course and Duration of Disease. Paralysis appears usually before the sixth day of the illness; it may occur as early as the first day. Other symptoms, except spinal and muscular pain and rigidity and skin sensitiveness, rarely persist. Non-Paralytic or So-Called Abortive Cases. Non-paralytic or so-called abortive cases are very frequent. In some epidemics they constitute from 25 to 50 per cent. of the diagnosed cases. The children have the early symptoms just mentioned, perhaps also the 304 muscular tenderness and spinal pain. If carefully observed it may be noticed that they develop a paralysis of one or more groups of muscles, but that instead of the paralysis continuing it all disappears within a few hours. It is obvious that the recognition of such cases is of extreme importance in controlling the spread of the disease. The diagnosis of such cases is greatly facilitated by an examination of cerebrospinal fluid obtained through lumbar puncture. General Care of Patient. Complete rest is of the utmost importance for either paralyzed or weak muscles for the first five or six weeks. Every effort must be taken to make this rest complete. The limb must not be allowed to dray on a paralyzed muscle. It should be supported by pillows or pads or bandages. There seems to be a greater tendency to atrophy if casts are used. A dropped foot may be supported by a sandbag or pillow ; small rolls placed under the knee often hold the leg in a more comfortable position. The weight of the clothing should be kept off the legs by hoops or other device If the head is somewhat retracted and the patient desires to lie on his back, he may sometimes be made more comfortable by a small pillow placed under the shoulders, allowing the head to fall back. The value of electricity for treatment in the first six weeks is very doubtful. In many instances it may do harm. Massage or passive movements should not be begun for at least five or six weeks and then should be used with great care. In cases that show a tendency to clear up rapidly, the child should be kept in bed for some time after the ability to use the muscles returns. It should never be encouraged to try to stand or to use the muscles otherwise until a consider- able time has passed. Pericd of Incubation and Duration of Disease. The incubation period has been officially set at two weeks. Non- immune, infected persons usually manifest symptoms of the disease in from five to ten days after exposure. The average period of incubation is seven days. The early symptoms, noted above, usually last from one to seven days. Quarantine of the patient will be maintained for a period of at least eight weeks. Prevention of Spread of Infection. 1. The children from an infected family will be confined to the house. (See ““ Quarantine.”) 2. During the continuance of an epidemic of poliomyelitis children should not be allowed to congregate in public places. 3. Fresh air outings or vacation camps are allowed, if kept under competent medical supervision, with an adequate physical examination of each child before enrollment and the exclusion of any child from an infected family. 305 4. Absolute cleanliness of all homes is essential; such cleanliness should include: (a) Screens in all windows. (b) Flies kept out of all rooms. (¢) Thorough cleanliness of all floors, woodwork, bedding and clothing. (d) Avoidance of dust (all sweepings should be done after the floors have been sprinkled with sawdust, bits of newspaper or tea leaves, all thoroughly moistened). (e) Garbage cans kept closely covered and washed out in hot soapsuds after they have been emptied. (f) No refuse, either of food or other waste, allowed to accumu- ate. 5. Personal habits of cleanliness are essential; the hands should be washed before each meal, after each visit to the toilet, and before going to bed. Children should be warned about putting the fingers into the mouth or nostrils. i 6. When sneezing or coughing, a handkerchief should be held over the mouth. Kissing of children is also a dangerous practice and should be avoided. Procepure To BE ForLowep iN Eaca Cask. Isolation of Patient. 1. Complete isolation of the patient must be maintained until ter- minated by order of the Department of Health. 2. A separate room must be provided for the patient. No one must be allowed iu this room except the attending physician, the nurse and the representative of the Department of Health. Care of Patient's Room and Surroundings. 3. (A) All rugs, carpets, draperies and unnecessary furniture must be removed before the patient is placed in the room. (B) All windows must be screened. (C) The sick room must be kept well aired at all times. (D) The woodwork must be wiped daily with damp cloths. Under no circumstances must the floor be swept when it is dry. It should be sprinkled with sawdust, bits of newspaper or tea leaves, all thoroughly moistened, and then carefully swept so that no dust may arise. (E) Toys and books used by the patient must be destroyed by burning after recovery or death. (F) Household pets must not be allowed in the room. Care of Bedding. 4. All cloths, bed linen and personal clothing which have come into contact in any way with the patient must immediately be immersed in a 306 five per cent. solution of carbolic acid and allowed to soak for three hours. They may then be removed from the room and must be boiled in water or soapsuds for fifteen minutes. Care of Discharges from Body. 5. A sufficient supply of gauze or clean linen or cotton cloth must be provided and all discharges from the nose and mouth of the patient received on these cloths. After use, they must be immediately burned or boiled. Bowel discharges and urine must be covered at once with chloride of lime and then disposed of by emptying into a water closet. Care of Utensils Used by Patient. 6. Plates, cups, glasses, knives, forks, spoons and other utensils used by the patient must be kept for his exclusive use and under no circumstances removed from the room or mixed with similar utensils used by other. They must be washed in the room in hot soapsuds and then rinsed in boiling water. After use, the soapsuds and water must be thrown into the water closet. Nurse. 7. A trained nurse or competent attendant must be in sole attendance upon the patient. She must not be allowed to mingle with the rest of the family but must be isolated with the patient. The hands of the nurse must be carefully washed in hot soapsuds after each contact with the patient and before eating. Termination of Case. 8. After the case has been ordered terminated by the Department of Health, the following procedure must be followed: (a) The entire body of the patient must be bathed and their hair washed with hot soapsuds. The patient should then be dressed in clean clothes (which have not been in the sick room during the illness) and removed from the room. (b) The nurse should also take a bath, wash her hair, and put on clean clothes before mingling with the family or other people. ActioN TAKEN BY THE DEPARTMENT OF HEALTH IN EAcH CASE. Placarding. Every house will be placarded without exception. In private houses one placard is placed on the street front (outside of house), and one placard is placed on the door entering the room patient is in. In tenements three placards are affixed, one on street door, one in entrance hall and one on door of apartment. All placards are dated. Quarantine. In all families where a case of poliomyelitis has occurred all other children under sixteen years except those who have had the disease are to 307 be quarantined in the home until two weeks after the termination of the case by death, removal or recovery. The patient, whether at home or in hospital, must be quarantined for eight weeks from onset of disease. Children under sixteen (16) years of age who have been, but no longer are, exposed to infection will be quarantined for fourteen days. Removal to Hospital. No case is to be left at home unless the following conditions are com- plied with: . (a) There must be a private physician in attendance regularly. (0) Person attending patient must obey quarantine rules; must not do any housework, marketing or leave premises. (c) Patient and attendant must have separate room. (d) All windows of rooms used by patient must be screened. (e) The family must have a separate toilet for its exclusive use. (f) Quarantine regulations must be strictly observed by patient and other children. Deaths. In case of death prompt burial is required, the coffin must be sealed as in deaths from other contagious diseases, and the funeral must be strictly private. Church funerals are prohibited. Spinal Puncture. Physicians desiring the services of a consultant to perform lumbar puncture and report on the examination of spinal fluid should telephone to the Bureau of Laboratories, Department of Health, 1600 Stuyvesant. Physicians desiring further information should write to the BUREAU OF PREVENTABLE DISEASES DepartMENT oF HEALTH, City oF NEW YORK 139 CexTRE STREET, NEW York CITY (PraAcarD.) (Issued July 15, 1916.) INFANTILE PARALYSIS (PoLiomYELITIS). Infantile Paralysis is very prevalent in this part of the city. On some streets many children are ill. Keep your children off the streets as much as possible and be sure to keep them out of the houses on which the Board of Health has put a sign. This is a disease which babies and young children get; many of them die; and many who do not, become paralyzed for life. 308 Don’t let your children go to parties or picnics or outings. Don’t let them play with any children who have sickness at home. The daily papers will tell you in what houses the disease is. If your child is sick, send for your doctor at once, or send word to the Board of Health. Manhattan, Centre and Walker Streets. Tel. 6280 Franklin. The Bronx, Third Avenue and St. Paul's Place. Tel. 1975 Tremont. Brooklyn, Flatbush Avenue and Willoughby Street. Tel. 4720 Main. Queens, 374 Fulton Street, Jamaica. Tel. 1200 Jamaica. Richmond, 514-516 Bay Street, Stapleton. Tel. 440 Tompkinsville. (LEAFLET.) (Issued August 10, 1916.) WHAT EVERY MOTHER SHOULD KNOW ABOUT INFANTILE PARALYSIS Infantile Paralysis (also called Poliomyelitis) is a catching disease caused by a tiny germ. The disease occurs mostly in young children, but now and then attacks older persons. . It is not difficult to recognize typical cases of the disease. Here is a common picture: A child previously perfectly well complains of a little stomach trouble or diarrhoea. It is feverish, restless and irritable. In the morning the mother finds that the child cannot stand or perhaps that it cannot move its arms. Parents should be on the lookout for all cases of illness in their children. No matter how mild it is advisable to seek a doctor’s advice. Don’t be misled by patent medicine advertisements. The country is already being flooded by announcements of quacks who want to sell their stuff. None of their medicines are any good. Camphor will not do any good. See a doctor! The germ of the disease is present in discharges from the nose, throat and bowels of those ill with infantile paralysis, even in the cases that do not go on to paralysis. It may also be present in the nose and throat of healthy children from the same family. Do not let your children play with children who have just been sick or who have or recently have had colds, summer complaint, etc. For this reason children from a family in which there is a case of infantile paralysis are for- bidden to leave their home. If vou hear of their doing so, report it at once to the Department of Health. Much can be done to reduce the amount of crippling caused by the paralysis. Remember that this requires the services of a trained physician and the care of a competent nurse. Unless you can give these to your child, send word at once to the Department of Health, so that the patient may receive proper care in a well-equipped hospital. Of the children cared for in hospitals, only one-quarter as many die as of those treated at home. Give your child a fair chance and let the hospital doctors care for it. 309 WaAT THE HEALTH DEPARTMENT WILL Do. If a case of infantile paralysis occurs in your home, your doctor must at once notify the Department of Health. An inspector will be sent to investigate. He will paste a sign on the door of your house and apart- ment warning all people not to enter. This sign must not be removed except by some one sent by the Department of Health. The inspector and nurse will tell you just what to do to protect yourself and the others in the family. Should you want any further information write or telephone to the DEPARTMENT OF HEALTH 139 CENTRE STREET, NEW YORK Telephone 6280 Franklin [The other side of this leaflet bore the following:] INFANTILE PARALYSIS IS DANGEROUS! CLEAN UP AND KEEP CLEAN! keep their hands particularly clean. Be sure that each child has its own clean handkerchief. Keep your house unusually clean. Don’t allow a fly in it. Keep your garbage bucket clean and tightly covered. Have a general house-cleaning. Throw away all useless knick-knacks and rubbish. Use soap and water generously, and let nature kill the germs with sunshine and fresh air. Kc your children clean. Bathe them frequently. See that they 310 Keep your children away from places where the disease exists. Don’t let your children play with groups of children. Don’t let them attend parties and festivals. Don’t take them to movies. Give them all the fresh air you can, but not on crowded streets, trolley-cars or boats. If you have a garden, keep the children there. Use the roof if you live in a house where there are no cases of the disease. Wash out your child’s mouth and nose frequently with Boracic Acid solution or plain boiled water with a little salt in it. Give your child cold boiled water (that has been kept covered) to drink. : Be careful of diet. Give light, easily digested food. Let your child have plenty of rest. Put it to bed early in the evening. Keep your child's bowels in good order. If you notice symptoms of fever, vomiting or tiredness, give a dose of Castor Oil. Put the child to bed in a room alone and CALL A DOCTOR. Keep all other children away until your child is well. COVER ALL FOOD THAT IS TO BE EATEN. (Press BULLETIN) From the nt of Health ray Henk OFFICIAL To the Editor: A very large part of the work of the Department of Health depends for its success on the co-operation of an enlightened public, and this, in turn, depends almost entirely on the amount of space accorded to health articles by the newspapers, If, when this reaches your office, your men are out on stories and you desire further information, we shall be glad to answer your inquiries over the telephone. Please ask for THE BUREAU OF PUBLIC HEALTH EDUCATION DEPARTMENT OF HEALTH «ase FRANKLIN 139 Centre Street, New York wo. RELEASE Frnrnsdiay PRESS BULLETIN. 7¢ Issued (Date) . . Scpb, 23 NEw Cases oF POLIOMYELITIS—SEPTEMBER 22, 1916. New Dropped as Total Total Cases. No Cases. Cases. Deaths. Deaths. Manhattan .......5.ce0. 445 9 oie 2,429 3 622 Bronk .i.o.ouisiiiiunies 3 587 2 137 BrobKIVy . oo es 5 ve 4,470 5 1,105 Oueens ........ Jude. dra 3 330 1,093 1 306 Richmond»... 0h ion ol 2 282 oe 56 Totabitor lion 20 8,861 11 2,226 " EEE EEE —_— Total Cases ina ospital id. ci. co SSL ttt ov sha mein FOR sia me sew a hE 2,823 Department Hospitals oon iu chin side shine vanish Bas ad Sais wai sins s aise 1,982 Other City Hospitals. riot nii Diht cette svi tha eT sai rs Lo Teenie 449 Private Ros Pl alr, Ei ah maa detain sled Wom iy mi wine Kon wlan 352 Swinbitne Aslan. ai. 0. Co. ir lived sn len 0 Sa el Bs vole 40 NANG eS rr rr a a te CT nl rr Mi Fem les 0s Sue 460 311 CASEs TERMINATED. Cases Cases Total Removed. at Home. Hospitals. to Date. Manhattan 5 32 28 979 Bronm fi. o.icvnid ss simi aves as ah bia 4 4 2 87 Brooklyn 4 7 19 1,412 Oheens tiv kon poh ede 2 4 7 187 Richmond oS oh “e 143 Total ine oan dine 15 47 56 2,808 Cert. Cert. Cert. Issued. Cert. Refused Issued. to Date. Refused. to Date. Manhattan. oo. lian. 8 362 48,144 hy 191 Bronx . oi. sich an tana 67 18,771 hel 56 Brooklyn i on Seid Shite a aa ven 343 59,490 = 217 Queens 5 dor ease 68 13,988 #5 3 RIAChINONA lec ree iin a Saiaind 18 2,107 i 5 Motale i. dari. onl vation 858 142,500 a 474 (Here followed an alphabetical list of the cases.) (CIRCULAR LETTER.) (Sent to all physicians in the city.) Office of the Commissioner. July 19, 1916. Dear Doctor: The present epidemic of poliomyelitis affords an unparalleled oppor- tunity for clinical study and observation. The Dé¢partment of Health, through the co-operation of various hospitals which are treating a large number of cases of polimyelitis, has arranged a series of clinical lectures open only to physicians, to be conducted by men who have had an unusual opportunity to study this disease. You are cordially invited to attend any and all of these clinics, and the Department hopes that you will take advantage of this exceptional opportunity. These clinics are to be con- 312 ducted during the week commencing Monday, July 24, at the following hospitals: Willard Parker Hospital— ; > Dr. Philip Van Ingen and Associates. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Kingston Avenue Hospital— Dr. Louis Ager and Associates. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Mt. Sinai Hospital— Dr. Herman Schwarz. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Bellevue Hospital— Dr. J. S. Ferguson (Isolation Pavilion, Ward 32). 4-5 P. M. Tuesday, Thursday and Saturday. Babies’ Hospital— Dr. Charles Gilmore Kerley. 4:30-5:30 P. M. Tuesday and Thursday. Swinburne Island— Dr. Frank Clark (Quarantine Station). 4-5 P. M. Thursday and Friday. Very truly yours, Haven Emerson, M.D, Commissioner. Receiving a Little Patient suffering from Infantile Paralysis into one of the Department of Health Hospitals. Withdrawing Spinal Fluid by Means of Lumbar Puncture for Purposes of Diagnosis and for Relief of Symptoms. vie Physician Putting on a Plaster Cast to Prevent Deformity. DEPARTMENT OF HEALTH GiTY or New York An Interesting Group of Patients. All Had Eye Paralysis, ore 317 A View of one of the Wards for the Care of Patients ill with Infantile Paralysis. 318 One of the Little Patients. Left Leg Paralyzed. Trained Masseuse Treating a Paralyzed Leg. 61¢ Convalescent Patients Were Placed on the Porches of the Hospital Pavilions. DeparTMENT oF HEALTI The Wards were Sometimes Crowded—but the Cribs were Effectively Separated by Glass Partitions. 12¢ a Another Crowded Ward (Queensboro Hospital). 323 escent Ward. 1 i a In the Conv Lawn Party of Children Ready to be Sent Home. vee 325 Maps. In the following pages are shown reproductions of the Brooklyn pin maps (the originals approximately 5 by 7 feet), on which all the cases were shown by means of pins. In the maps here given the cases have been plotted according to the date of onset, a method which furnishes an accurate picture of the course of the epidemic. S) N RR ¢ SN ) KS egy Wa AP at GER Me lavatie RT 2 oY A EL SR AN) SAR ANN BAe A \ 15% A SR Ai 07% LATS Rae NR SL AY jn 3 A Be Onsets in Month of May, 1916. 18663—Beals—N. Y. 326 VLE RS Ty MAL OF "BROOKLYN SCALE 1000 FEET TO AN INCH Onsets in First 10 Days of June, 1916. 18665—Beals—N. Y. 327 Onsets in Week Ending June 17, 1916. 18666—Beals—N. Y. WE rd ng fdiasdi TIE Lio bi Ly TERS» 1 MAP OF Vy ROOKLYN SCALE 1000 FEET TO AN INCH ee Onsets in Week Ending June 24, 1916. 329 Ned Cavin MAP OF \ * BROOKLYN SCALE 1000 FEET TO AN INCH Lops Onsets in Week Ending July 1, 1916. 330 Nii Th eZ hr 8 ye 3 LATTA Ita ST : ; , i ARR PRT : eT el iT AVANT fit er ai] lier Was SA RR a] Oh i fi D /! 1h RS 4 pa hy tabs ET ay REIN ht En Onsets in Week Ending July 8, 1916. 331 ad Ts Onsets in Week Ending July 15, 1916. 332 5 RSE MAP OF ROOKLYN prit SCALE 1000 FEET 10 AN INCH Onsets in Week Ending July 22, 1916. 333 SCALE 1000 FEET TO AN INCH rr Onsets in Week Ending July 29, 1916. 18698—Beals—N. Y, 334 Onsets in Week Ending August 5, 1916. 18701—Beals—N. Y 335 CARE A Ped Lb md ahead Onsets in Week Ending August 12, 1916. 18702—Beals—N. Y. 336 Onsets in Week Ending August 19, 1916. 18711—Beals—N. Y. Onsets in Week of August 26, 1916. 18712—Beals—N. Y, 338 Y. 18713—Beals—N\. 1916 Onsets in Week Ending September 2 339 SIR as 2 MAP OF v ' BROOKLYN SCALE 1000 rey To AN INCH wea fais oe Onsets in Week Ending September 9, 1916. 18714—Beals—N. Y. 340 « WAIST y MAP OF 5 * BROOKLYN SCALE 1000 FEET TO AN INCH Onsets in Week Ending September 16, 191€. 18715—Beals—N. Y. ————— D1wapidy 916] Ul SIse) ukpjooig JO UORNGLISI(] nay noo 957 aii § sowssohnss wan An don eee) o tenby ANN SVIg > 3 % : , e op ge woos NATHOOHY 2 jo ygnouog ayy, dO JVI RO TB NN 60—Beals—N. Y. EE esd ER RL fh A. i sabes ™m.] N Ie SOF aly P ad mtn at hs AL win fj igh AG ess © mE 3 Hl i J ol 14 3 Beat, ALE BOROUGHS FURNISHED oN THiS s0aLE > Sens w Fear PRICE 220 u an =r Yow iw SE lig bead that 41 ! faa rt aS, 3 LG ahaa ions Labifats tates sin Lat ber iY SADDER ern ———y | ca ppm pend, ag Aa ahh 3 elo ie i okie ci db fi rand] ETO AAS Distribution of Cases in 1916 Epidemic in Queens. tated wid FE ol ' : { i t hada A Rll 2 TET ITT 119 was called and pronounced the case not serious—only a gastro- intestinal attack—and recommended that the child be kept in bed for a day or so and then allowed to get up. At the end of this period the mother found that the child moved with difficulty, as its legs were stiff. The attending physician was again called and stated that this condition amounted to nothing and would disappear within a few days, which it did. “*On July 5 a child belonging to another family of this group also became ill. In this instance the symptoms of polio- myelitis were well marked and the family physician notified the Department of Health. The child was visited by a health official, declared to be a case of poliomyelitis, and removed to a hospital. “ ‘Evidently the circumstances relating to the illness of the child first affected were not officially reported. When the second case was announced, the mothers whose children were not ill promptly left New York with their families and went to a boarding house in an adjoining State to escape infection. Before July 10, all the children of this group were attacked with polio- myelitis. One died, and evidences of paralysis appeared among the others. Although the report of this occurrence obtained from the families of this group bore every evidence of veracity, it was deemed important that it should be properly verified. Therefore, the health officer of the township where the boarding house was situated was communicated with. He confirmed the statement already made, declaring that in his opinion all of the children had had poliomyelitis.’ ; “The example clearly shows that the first child affected was an abortive or unrecognized case of poliomyelitis, and was the source of infection to the other. “Finally and in this connection a word may be added on the subject of the healthy carrier of the infectious agent of poliomyelitis. Our study, because of its nature, could not take cognizance of this factor, except to the extent of excluding it when possible by obtaining evidence or indication, in cases of suspect carrier infection, that con- tact with an actual case of the disease had taken place. We have no figures to present on this very difficult topic; but we believe that the more incisively the matter is investigated, the greater will the actual number of contacts with actual cases be found to be. INcuBATION PERIOD. “To establish a determined period of incubation during an ex- tended outbreak of such an infectious disease as the one we are con- sidering in a thickly populated city, in which infection is widespread and cases are continually occurring, involves difficulties and uncer- tainties which seriously affect the validity of the result achieved. “Tt is, of course, far easier to establish an apparent period of incubation. In sparsely settled communities the former is often capable of accurate estimation; in thickly populated communities, the latter has always to be dealt with. Thus the period of incubation in connection with a group of infected persons in which more or less continuous association is going on cannot be accurately fixed. On 120 the other hand, when one child in a family falls ill of poliomyelitis and a second child develops the disease six days later, the incubation period is usually put at six days. And yet, as we cannot ascertain the precise moment of infection, it may actually be less than that period. ; “The other extreme is that in which a second or subsequent case of poliomyelitis appears within a day or two of the first, suggesting coincident infection, which is what it probably is. And yet, even this involves an assumption regarding the incubation period which may be incorrect. Instances of so-called determined incubation periods, as brief as two days, have been given by certain authors; they arouse, however, grave suspicion as to their validity. “In our tabulation we have tried to distinguish between the apparent and determined incubation periods; 584 cases fall into the first and 15 into the second category. It is interesting to observe that one-third of the latter fall on the third day and two-thirds within eight days. But a greater number of instances of “determined” incubation periods must be assembled before we shall know whether the figures obtained in our investigation represent the true periods. “No further comments on the apparent period are perhaps called for. The large number of instances following in the first three days is noteworthy, but cannot be regarded as in the nature of conclusive testimony in favor of a very short incubation period. In other words, the question is left by our study approximately where it was, the critical time falling within the first seven or eight days of exposure. “Tt has occurred that a period of two or three weeks has elapsed, or seems to have elapsed, between the onset of a first and second case in a family. The question arising is whether the long period is to be regarded strictly as incubation time or whether the associa- tion may not have existed for several days before actual communica- tion of the infectious agent took place. Of the two alternative possi- bilities, the second seems more likely. SUMMARY. “The investigation carried out by the field force of your com- mittee, under my direction, has supplied information of two kinds: “ First, information of practical daily import was obtained by the physicians and nurses who visited premises in which cases of poliomyelitis occurred and the relatives and friends of the affected families, which was turned over immediately to the Department of Health for its use and guidance. “ Second, the data thus collected and recorded were subsequently collated and analyzed in the hope that light might be thrown on the important questions of source of infection, period of incubation, types of disease, significance of food, of diseases among domestic animals, insects, and some other subsidiary topics. “This second line of inquiry yielded information which led us to regard the disease as one (a) communicated by personal contact, (b) in which the slight and abortive cases are the most frequent sources of the contagion, and (¢) in which the incubation period varies between three and ten days. We were not able to make a study of the question of the healthy carrier, but we think it probable that 21 he plays a less conspicuous part in disseminating the infection than does the mild and often unrecognized case of the disease. “We gave especial attention to the working out of the incuba- tion period on the basis of the data collected. Recognizing the diffi- culties and fallacies of the undertaking in a large, miscellaneous popu- lation, such as exists in Greater New York, we cannot assert that our conclusion is absolute. We think it probable, however, that taken together with the conclusions of previous investigators, it is virtually correct. “We could, finally, find no substantial evidence to support the notion of food, lower animal or insect carriage of the infection, although in regard to those subjects our investigations were inci- dental rather than essential.” Multiple Cases— In order to determine the frequency with which more than one case occurred in a household, a special investigation was made of multiple cases in families. Out of the total number of cases for the year 1916, 8,635 families were involved. Multiple+Cases of Poliomyelitis in Families. Number of Cases in Family Manhattan ~~ Bronx Brooklyn Queens Richmond City Two .... 05 13 159 61 13 33 Three ... 5 1 20 1 1 28 Four ...: 1 0 3 1 1 6 Totals . 71 14 182 63 17 347 (1) 8287, or 96%, had one case only. Total children in these families were 24,883. (2) 313, or 3.6% had two cases; 28, or .3+%, had three cases; 6 or 06+% had four cases. Total children in these three groups of families were 1,516. Total cases 736. Thus, multiple cases occurred in only 49% of the families involved— while in the first group, we find that over 16,500 children, intimately exposed to the infection, did not contract the disease. The investigation showed that, in nearly all instances where more than one case occurred in a family, the onsets were so close as to suggest simul- taneous infection. Some cases were found to have been attacked with the disease at a later date, indicating that they were probably secondary infec- tions, but such cases decreased in number, as a rule, with increasing length of time from the first case. Very exceptionally were secondary cases sepa- rated from the primary case by a longer interval than two weeks. Similar results were obtained in the study of multiple cases in one house; the ma- jority of the cases would appear to have had a simultaneous infection. 122 In a study of forty cases, where more than one case occurred in a family, 10 cases occurred 1 day from primary case 2 “ “ 2 days “ “ 3 ‘“ [lg 3 € “ [a [3 1 case “ 4 [a [I £“ € 3 cases \ 3 € [4 6 cc c € £“ 2 ““ [ 7 “ i c €« 1 case cc 10 cc €< cc € 1 “«“ [4 13° ‘“ cc 6 cc 734 cases were reported with an onset of five days or less. As the diagnosis of poliomyelitis was held in abeyance by many private physicians until evidence of impairment of muscular function was apparent, this is also of value in showing the early occurrence of paralysis. Of 1,500 of the total cases in which the matter of previous exposure was studied in detail by a representative of the Department of Health, it was found that in 29 cases there had been direct exposure to another case in the same family ; in 25 instances the fatal case had been exposed to cases out of the family; in 13 cases a member of the family had visited active cases of poliomyelitis within a week of the onset of the disease in the fatal case. The exact date of first exposure as related to the date of first observa- tion of symptoms in the fatal cases could not be learned, so that any positive conclusion as to whether the cases above recorded were secondary in the accurate epidemiological sense of the word, or merely subsequent and arising from quite other and common source of infection, cannot be offered. Regarding the degree of contagiousness of this disease, an interesting comparison may be made of the incidence of diphtheria, scarlet fever and measles, in a crowded area of the city, during their period of greater activ- ity, with the recent incidence of poliomyelitis in the same section. In both scarlet fever and diphtheria we recognize considerable natural immunity. Further, in diphtheria an immunity is commonly conferred by artificial passive immunization of exposed persons. The area selected for this comparison was the congested “ East Side ” of Manhattan, a district lying between Broadway and East Third Street to East River, known as the Corlears District, having a total population of about 430,000 persons. Comparison of Incidence of Contagious Disease, Corlears District. €« 5 “ € € €“ January February March April May Diphtheria '...5..000:04 132 103 122 123 139 Scarlet Fever .......... 41 36 35 59 66 Mieaslest =. inns viids 25 58 186 287 288 June July August Sept. Oct. Poliomyelitis .......... 13 189 154 20 4 TE Tr nT Ty. TT EN I ht — 123 These figures would seem to indicate that poliomyelitis is certainly no more readily communicable than are diphtheria, scarlet fever and measles, and one might fairly conclude that with immunity to this disease as evident as that recognized in the other so-called “ contagious diseases,” in a fixed population, its communicability is decidedly less. Overcrowding— In order to determine whether there was any relation between conges- tion and the spread of the disease, the following summary of data collected by the Tenement House Department is interesting: In the Borough of Manhattan, out of 614 cases of poliomyelitis occur- ring in tenements, the largest number of cases, 152 to the tenement, occurred in tenements of eighteen apartments; quite a large number of cases occurred in tenements of three to ten apartments, but the smallest number of cases occurred in tenements of thirty to ninety apartments to the tenement. In the Boroughs of The Bronx, Brooklyn, Queens and Richmond, a similar comparative incidence of cases was found; the smallest number of cases occurred in the tenements with the largest number of apartments to the tenement. In a study of 1,000 cases taken from the files in the Borough of Brook- lyn 241 cases occurred in private houses, 12 cases occurred in boarding houses, 747 cases occurred in tenement houses. This would seem to show that the class of dwelling had little bearing on the case incidence of the disease. These facts are still further confirmed by observations made in particu- larly crowded sections of the city. A small and quite isolated residential district in Manhattan lies west of Broadway, between Battery Park and Liberty Street. The 1910 census of this area gives a population of 6,441, with 1,463 families. There has been little change since then. The social and economic conditions are probably as bad as can be found anywhere in the city ; the housing is wretched ; there is a great deal of overcrowding, the residential section being greatly encroached upon by business buildings. Another section, the old “East Side” of Manhattan, south of East Third Street and East Broadway to the river, may be compared with this. Here a very conservative estimate of the population is 400,000. In all respects, it is quite comparable to the other district. In the Battery Park district, with its population of about 6,500, there were twelve cases of poliomyelitis, or nearly two per thousand. In the East Side, or Corlears District, there were 342 cases, or 0.8 per 1,000 population. From these data, it would appear that there was no real relation be- tween overcrowding and the spread of the disease. 124 Domestic Animals as Carriers— In order to determine whether domestic animals of any kind, being affected by the disease, might become the source of infection, special in- vestigations were made by the Department of Health of all sick or paralyzed household pets, chiefly dogs and cats, discovered in premises from which poliomyelitis had been reported. With the co-operation of the American Society for the Prevention of Cruelty to Animals, all such animals were removed to the Shelter of the Society and there studied. The following comparison by years, for the months of June, July, August, September and October of the number of dogs and cats removed by the American Society for the Prevention of Cruelty to Animals shows the marked increase of the activities of this Society during the epidemic: Dogs Cats Month 1914 1915 1916 1914 1915 1916 June naan 3,955 3,669 4,345 20,559 22,082 32,099 July els eeseii conn 4,119 4,105 5,546 22,161 29,236 94,991 August us ionivinn 3,258 3,873 4977 22,459 28,8345 62,204 September ....... 5,520 3,977 4,034 17 462 24,057 45,888 October ...-. «x 4,788 3,745 3,636 11,3587 20,916 34,586 Fotals csi. « 23,640 19 369 22,538 94,198 125.136 269,763 As the result of these investigations, nothing was found to indicate that these animals were affected by the disease or that they acted in any way as carriers of the infection. Food and Milk— In previous epidemics, the theory has been repeatedly advanced that food or drink may act as vehicles of infection in poliomyelitis. The regular water supply and various foods and drink, particularly ice cream cones and soda water, have been under suspicion and investigation. Above all, milk seems to fit the requirements as a medium of infection, although it has never been proved to transmit the disease. Tt was decided by the Department, therefore, to make a special study of the milk supply, in cases of poliomyelitis occurring in New York City, and that so important a food might be properly covered, it was determined to apply, in one borough (The Bronx), the same searching analysis of the milk supply, in poliomyelitis, as is employed in the study of typhoid fever. The general plan adopted was as follows: First, careful inquiry as to the milk used during four weeks previous to the onset of the infection ; second, ascertainment of the name of the dealer, in the case of bottled, and the address of the store from which it was pur- chased, in the case of loose milk; third, in each case, tracing the milk to the country; fourth, close watch kept by elaborate tabulations, on both the dealers and creameries (i.e., country shipping points) ; and fifth, when any number of cases were charged to a given creamery, prompt investigation at the source of supply, to discover possible contamination. Data were carefully kept and tabulated by onset by weeks of all cases 125 supplied by milk dealers. This tabulation included five hundred twenty-five (525) cases who had been served with milk by thirty-three (33) dealers. Several dealers showed a decided accretion of cases; in one instance, of one hundred ninety-seven (197) cases, and in another, of one hundred seventy-one (171) cases. At first glance, this would seem to lead to a ‘suspicion of individual dealers, but on further consideration it was apparent that the increased accumulation of cases was consistently in accord with the varying amount of milk distributed by each company in the area studied. The milk involved was largely Grade B pasteurized milk. Some Grade A milk from country pasteurizing plants showed moderate accumulation of cases, in the last week of July and the first week in August. These plants were specially investigated, in the manner above indicated, as in typhoid fever. The result was altogether negative. Several smaller studies made by the Department, in the course of investigation of food stores in Brooklyn, gave similar results. One investi- gation, in the Bay Ridge section, showed twenty-four cases of poliomyelitis using milk from twelve different sources. The other, in a different part of the borough, showed fifty-one cases, with seventeen different sources of milk supply. Of 30,375 babies under two years of age, who were cared for at the Baby Health Stations in New York City, from June 1st to October 1st, 199, or 0.65 per cent., were affected with poliomyelitis, of which number 59, or 29 per cent., died. These babies were affected and succumbed to the disease, regardless of whether they were fed on breast milk exclusively, on bottle milk exclusively, on mixed feeding, or given Grade A Raw, Grade A Pas- teurized or Grade B milk. Especially, it is to be noted that, out of 115 babies under one year of age affected with poliomyelitis, 41 were fed on breast milk exclusively, and of this number 6 died of the disease. Like results were obtained in a study* of 199 cases under two years of age, admitted to the Willard Parker Hospital. Of this number, 42 of the babies affected were exclusively breast-fed, while 97 of the artificially fed babies were given pasteurized milk, a small percentage only receiving pro- prietary food. In all these investigations there was nothing to indicate that, in the recent epidemic, any food or drink was concerned in the spread of the disease. Milk at least would seem to have been eliminated as a source of infection in poliomyelitis. Relation of the Epidemic to General Mortality Under the Age of Two Years— In studying the relation of poliomyelitis to the infant mortality and to the mortality of children under two years of age in the Greater City, it will be found profitable to analyze the situation from the following standpoint: (a) The relation of the epidemic to infant mortality, that is, to the deaths of babies under one year of age in the Greater City. * By Dr. May G. Wilson, Cornell University, New York City. : 126 (b) The relation of the epidemic to the mortality of babies under two years of age in the Greater City. (¢) The relation of the epidemic to the infant mortality as to deaths of babies under two years of age enrolled at under the super- vision of the fifty-nine Baby Health Stations in the Greater City. (d) The relation of the epidemic to the infant mortality of babies under supervision of district nurses during July, August and the greater part of September. For the purposes of this study, comparisons will be made between the first nine months of the years 1915 and 1916, inasmuch as, from the prac- tical standpoint, it may be said that the epidemic had spent the greatest part of its course by October 1, 1916, and in view of the fact that the opening of the public schools received official sanction on September 25, 1916. At the outset we desire to submit the following tabulation of compara- tive statistics bearing upon an analysis of this situation, and to which we will refer from time to time in discussing the many phases of the subject: (A) Relation of the epidemic to the infant mortality—that is, to the deaths of babies under one year of age in the Greater City: Despite the epidemic of poliomyelitis, the infant mortality situation in the Greater City, both from the standpoints of rate and number of deaths under one year, has been exceedingly favorable. The infant mortality rate in the Greater City for the year 1915 was 98.2 per 1,000 children born. For the first nine months of 1916 we find the infant mortality rate 98 as against 102 for the corresponding period of 1915. This took place in face of the fact that some 961 infants, or about 119 of the total cases reported, were attacked with the epidemic disease, and that 395 of the infants attacked succumbed. (See Table XXIII in the Appendix.) Various observers, or rather critics, have presented several reasons for this reduction in infant mortality during the year, among which may be mentioned : (1) The reduction in the number of births; (2) The fact that, owing to the prevalence and spread of the epidemic, a larger number of infants were taken out of the City this year than last year; (3) Because of the greater exodus from the City of infants under one year, a larger number of these infants died outside of the City limits, and the deaths were, therefore, not included in the total number of City infant deaths. To answer these seriatim: (1) The Reduction in the Number of Births— It is true that there have been some three thousand eight hundred and forty-one less births this year than last year (see Table XXIII, item 1), and that with so many thousand less births, it is to be expected that there will be numerically fewer deaths. This does not alter the fact, however, that the infant mortality rate, which is a true index of the infant mortality situation, and which is based upon the number of births during the year, and the num- 127 ber of deaths under one year, occurring during that year, is lower than for the corresponding period of last year. (See Table XXIII—item 5.) But even from a numerical standpoint, the number of infant deaths for the first three-quarters of 1916 would have been lower than for the corresponding period of 1915, even had these 3,841 infants been born. Assuming that for every thousand children born, one hundred would have died before the first year, we would have had some 384 more deaths than were actually recorded for 1916, namely, 10,122. (See Table XXIII— item 2.) The present figures show that for the first three-quarters of 1916 there were 884 less deaths under one year of age than for the corresponding period of last year. (See Table XXIII—item 2.) If we add to the number of infant deaths for 1916 the 384 which would have taken place had the number of births in 1916 been as large as 1915, we would still find that there were 500 fewer infants dying in 1916 than in 1915. It cannot, therefore, be denied that despite the reduction in the number of births during the year, there has been a distinct numerical saving in infant lives. (2) Larger Number of Infants Taken Out of New York City in 1916? It is manifestly impossible to secure any absolutely reliable data on this subject. Impressions vary, some inclining to the belief that the number of families and infants under one year leaving the city this year was greater than last year, and others taking directly the opposite view. At first thought it would seem that the prevalence of the disease, and the terror which it struck in the hearts of the parents, would cause a great exodus from the city. It must be remembered, however, that within a very short time after the epidemic had gained a foothold, quarantine regulations became rather rigid, and entrance to other cities and summer resorts near New York was rendered most difficult, so that a large number of parents who actually desired to take their infants away were prevented from so doing. Other parents, again, soon found that the disease had found its way into the very cities and towns which they desired to visit, and they realized that their children were just as safe in New York City, in fact, safer, because of the better facilities, than outside of New York. Many parents were so taken up with the fear of the disease, that they remained in the city. As they put it, if the child should be attacked far away from home, they might have great difficulty in returning to New York, and in securing for it the proper medical nursing or hospital care. It seemed probable that at the beginning of the epidemic not a few families, particularly among the Italian population of the Borough of Brooklyn, and the Jewish tenement dwellers of the lower East Side of Manhattan, became panic-stricken, packed up bag and baggage and left the City. This, however, was the exception. It must be remembered that many of the better situated element of the population who leave the city during the summer months, year in and year 128 out, remained in the city this summer, either because of the strict quarantine regulations, both here and in other cities, or because of their desire to remain in a large city, with all its conveniences of transportation and treatment in the event of illness. This number, in our opinion, more than counterbalances the number leaving the city at the beginning of the epidemic. In order, if possible, to determine with reasonable accuracy whether the removal of children from the city during the summer materially affected the infant mortality of the city, an inquiry was sent to passenger agents of all the railroads having a terminal in New York. Replies were received from all of them, and while many of the roads were unable to supply us with the exact figures, the consensus of opinion was that there had been a material decrease in the summer traffic, particularly as far as children were concerned, as may be seen from the following quotations from the replies received: “We notice a decided falling off in the ticket sales for both adults and children.” *“ We know, however, from personal observation, that during the first outbreak of infantile paralysis, before the quarantine was estab- lished, that a large number of children did leave the City, but after the quarantine was established, comparatively few did so.” “Our records show that in July, 1915, we sold 6,622 tickets for the use of children under twelve years of age, whereas in July, 196, we sold 4,106. In August, 1915 we sold 4,622 for children under twelve years of age, and in August, 1916, we sold 637 such tickets.” “ Approximately 300,000 adults and 7,000 children left the City during July of this year. For the same month last year 270,000 adults and 7,000 children. During the month of August this year about 250,000 adults left the City and 2,000 children. During the same month last year 245,000 adults and 6,000 children.” “In the sale of half tickets there was a decrease of 4,616 tickets in July as compared with that month last year, and a decrease of 6,579 in August as compared with the same month last year.” “It would be exceedingly difficult to obtain the exact statistics from our records, but an examination of the reports of our principal New York offices for the period mentioned indicate a decrease of approximately 35 per cent. in the number of tickets sold during the months of July and August, 1916, as compared with 1915.” Concerning the relative number of children leaving the City, our gatemen estimate that there was a slight increase in July and August, 1916, compared with the same period of 1915 in all rail, but a considerable decrease in the children handled over the ferries.” It would seem that there was certainly a decrease in the amount of travel of children during the summer. This does not of necessity, however, mean that there was a decrease in the number of children who left the city, but rather that when children were taken from the city they did not return until the epidemic was over, and that there was a decrease in the number of excursions to and from the city. Convalescent homes, because of the edict against gathering of children 129 in groups, naturally received fewer cases of infants and children than last year. Many of them, in fact, closed their doors. Further effort was made to obtain fairly accurate data as to the com- parative number of infants who left the city during the summer of this year, as compared with that of last year by questionnaires addressed to medical inspectors of the Department, who were engaged in general practice, to nurses engaged in school medical inspection, i through inquiries made of 31 public school principals. As a result we have the opinion of 43 ish that there were more little children who left the city in 1916 than in 1915, and 27 who believed the opposite to be the case. Four thought there was no difference. The inquiry of the nurses showed the following : 1915. 1916. 6,711 8,000 children under 2 in families under observation. 5,967— (89%) 7,022— (87.9%) remained in the City. 744— (10.9%) 982— (12%) left the City. The inquiry carried on through the school principals, which involved a study of families with a total of 19,105 children of twelve years or over, and 2,068 children two years or under, seems to be a better basis upon which to base an opinion than any one of the others above mentioned, representing a fair cross section of the movements of families with children in- the populous Boroughs of Manhattan and Brooklyn. The conclusion is quite definite that fewer children of two years or under left the city in 1916 than in 1915. (3) Larger Number of New York City Infants Dying Outside of the City— The third criticism advanced, namely, that a much larger number of infants died outside of the city limits in 1916 than in 1915 is not justified by any of the figures that we have at our command. In the answers received from the 74 medical inspectors (physicians in general practice) canvassed, we have reports of two deaths occurring out- side of New York in 1916, as against none in 1915. In the study made through the 31 public school principals, the number of deaths occurring outside of New York City in 1916 was eight, and in 1915, five. That we might determine exactly the number of children who died outside the city during the summer months, whose deaths should be charged against the city, the Registrar wrote to the State Departments of Health of New York, New Jersey, Rhode Island, Massachusetts and Connecticut, asking them to supply us with the information called for in a qu 1 3 1 7, 3 Broncho and Lobar Pneumonia. . . . 9 4 5 oh on 1 2 “3 vs 6 Allothercauses. ....... 0 evar 247 150 97 2 - 2 2 5 9 227 Total... .ouiciiniiis ine: 290 173 117 4 7 15 15 13 236 Deaths in New Jersey of Residents of New York City During July, August and, September, 1916. Total—All Ages. Under Under 2to4 5t09 "10to 14 15 Years One One Two Years Years Years and Total Males Females Year Year Years Inc. Inc. Inc. Over Anterior Poliomyelitis............. 13 6 7 os 1 2 7 2 1 Diatrhoeat yo vel ie wild vai ah 8 2 6 4 2 1 ‘e oe 1 Broncho and Lobar Pneumonia. . . . 20 13 7 5 i P 2 2 or 16 All other canses. ..... vv vessiv'vv in 320 224 105 wid ou Zz 3 5 3 312 Total. i. ws itis, 361 245 125 8 5 8 14 5 330 Deaths in the State of Rhode Island of Residents of New York City During July, August and September, 1916, Total—All Ages. Under Under 2to4 5109 10 to 14 15 Years in One One Two Years Years Years and Total Males Females Year Year Years Inc. Inc. Inc. Over Anterior Poliomyeélitis........us es 1 va 8 mos. Diarrhoea... ivnsnswsn sonswess = Broncho and Lobar Pneumonia. . . . Allother causes... ..5 sires ine 0¢T subad Deaths in the State of Massachusetts of Residents of New York City During July, August and September, 1916. Total—All Ages. Under Under 2to4 5to9 10 to 14 15 Years = One One Two Years Years Years and Total Males Females Year Year Years Inc. Inc. Inc. Over Anterior Poliomyelitis............. 1 5% 1 5 er : va 1 DIAITNOea. od ov lin shin mds ek Broncho and Lobar Pneumonia. . .. All other causes... .o.civsay cans Total. .ovicciviveive a, 1 1 1 Deaths in the State of Connecticut of Residents of New York City During July, August and September, 1916. Total —All Ages. ——te——— Under 1Yearand 2to4 S5to9 10 to 14 15 Years Total Males Females Year Under 2 Years Years. Years. and Inc. Inc. Over Anterior poliomyelitis... .. on. v visi vainniaes 15 10 3 1 2 3 7 1 1 Ey RL 2 2 1 ou 1 oe Tp a Broncho and lobar pneumonia. .............. i: ee iY oe i Xo All other causes’, hh Ji us vi wens wdiivinate 41 19 22 1 1 1 2 i 35 Matalin ey 58 31 27 3 3 5 9 2 36 Ie1 132 The opinion is therefore fairly borne out that none of the criticisms which have been directed against the estimated reduction of infant mortality along the lines aforementioned, namely, decrease in birth rate, increased exodus from the City, and increase in number of deaths of infants taking place outside of the City, are justified, and that the reduction in infant mortality during the past year was a genuine one, and for reasons which will be given later in this report. If criticism has been directed against the reduction of infant mortality in general, it has been particularly directed against the marked reduction in the number of deaths from diarrhoeal diseases. For the first nine months of 1916 there were (Table XXIII—item 15) 1,965 deaths from diarrhoeal diseases as against 2,626 deaths from the same cause for the corresponding period of 1915, a numerical saving of 661 deaths from these diseases. This criticism was to the effect that a large number of the deaths ascribed to infantile paralysis were due to diarrhoea, and that, therefore, the number of deaths from infantile paralysis in infants should have been less, and correspondingly, the number of deaths from diarrhoea in infants should have been greater. The total number of deaths from poliomyelitis under one year of age during the first three-quarters of 1916 (Table XXIII—item 8) was 395. For these three quarters of 1916 there were 661 less deaths from diarrhoeal diseases in infants than for 1915. If we grant, for the sake of argument, that the majority, or all of the 395 deaths ascribed to infantile paralysis in infants were, in reality, infantile diarrhoea, there would still be a saving of 266 infant lives from diarrhoeal diseases and if, to satisfy the most exacting critic, we apply the infant mortality rate from diarrhoeal diseases, of 24.5 per thousand births, to the 3,841 less births which occurred during the year, and subtract these 93 cases from the 266 above number there would even then be a numerical saving of infants from diarrhoeal diseases to the number of 173. There is nothing unusual or unexpected in a marked reduction in deaths from diarrhoea in infants. This is rather to be expected. In point of fact the deaths of children under one year of age from the four principal causes for the years 1884 and 1914 show a per cent. reduction as follows: Contagions: DISEISes i ow ribs in aiss brs waists 88.7 Diarrhoeal Diseases. ic iii shan sans s Lhe sn i 75.7 Respiratory DISeases ii sh hte don tier wis asinine 53.4 Congenital. Debllity iii sha vt vale] i450 suis Ls Similarly it will be seen that there were fewer deaths from respiratory diseases and from contagious diseases in 1916 than in 1915, so that it is evident that increased care of infants has been conducted all along the line during this year. (Table XXIII, item 15.) 133 In analyzing the reduction in the number of deaths from diarrhoeal diseases, it may be interesting to note the following: Deaths From Diarrhoeal Diseases. In Institu- In Dwell- Year. tutions. ings. Total. JOS rid th ert So na iecs 136 Fenians Swiivin 919 1,707 2,626 (35%) (65%) (100%) 17 1 Ct ee PR nT 668 1,297 1,965 (34%) (66%) (100%) 251 410 661 ReduetiofmIOl ..uvvsissusnssesnvisaressssestss Here it will be seen that a reduction took place in institutions as well as in dwellings, and that the percentage of cases in institutions and dwell- ings was practically the same during the two years. If we grant that there were a certain number of cases of diarrhoeal disease diagnosed as infantile paralysis, it is surely equally true that, par- ticularly at the beginning of the epidemic, a certain number of mild cases of poliomyelitis with gastro-intestinal symptoms were diagnosed as diarrhoea. While it is possible that there may have been the normal incidence of error in the diagnosis of some of these cases, just so it is possible that cases of diarrhoea in this and former years were due to poliomyelitis; but to say that the marked reduction in infant deaths from diarrhoea was due to the listing of diagnosis of these cases as poliomyelitis is unjustified and un- warranted by the facts of the case. We find that the mortality of babies under two years of age during the poliomyelitis epidemic has remained favorable and better than last year. The mortality rate of babies under two years is based upon the estimated population at that age, and the figures for 1916 (Table XXIII, item 6) show a mortality rate of 72.7 as against 78.5 for 1915. In 1916 there was a diminution in the number of deaths under two years of age to the extent of 764 (Table XXIII, item 4) and this, despite the fact that the estimated population at that age for 1916 exceeded that of 1915 by almost 6,000. The number of deaths under two years of age from the various groups of diseases in children under two years of age (Table XXIII, item 16) was less in practically every instance than in 1915, and the mortality rate of babies under two years of age for the various groups of diseases (Table XXIII, item 18) was also less, in most instances, than for 1915. During the period of the epidemic (Table XXIII, item 25) it will be seen that the mortality rate of babies under two years of age from the vari- ous groups of diseases was lower in 1916 than in 1915. 1,725 babies under two years of age were afflicted with poliomyelitis, or 0.7 per cent. of the estimated population at that age, and of these 886, or 51 per cent., died. (Table XXIII, items 10 and 14.) 134 It will be seen from the figures submitted that the infant mortality and mortality of children under two years of age from anterior poliomyelitis is greater than at all ages, 41 per cent. of those under one year affected dying and 51 per cent. of those under two years of age affected dying, as against a case fatality of 26.3 per cent. at all ages. (Table XXIII, items 7, 8,10, 11, 13 and 14.) The analysis of the deaths under one year of age and under two years of age, by boroughs, shows, as noted in the table below, that in both instances the percentage of deaths was largest in the Borough of Queens. Percentage of Deaths From Poliomyelitis by Boroughs—Under One Year of Age. No.of Cases No.of Percentage Borough. Reported. Deaths. of Deaths. NeW York Cy. i iia cnsirrmntnman ss snmeininnss 961 395 41.1 Manhattanih oi... TTT oe die 326 142 43.5 BrooKIVI., oso vurrisitine sa meenin or 4% pennies + 460 179 38.9 OREIBIONT &..f Soars renee s vis inmd nd dda wwii 62 23 37 hn rE SE aE 97 44 45.4 REGAIN sav iinariiins ios naneinn ss i osmaininsens 16 7 43.7 Under Two Years of Age. No.of Cases No.of Percentage Borough. Reported. Deaths. of Deaths. NeW ot City. vas vvsis s Dustin dine i 2 sn viisnnevins 1.72% 886 51.3 Manhattan: 0. souvaies s vrismnnsins so sos sions ote 331 279 52.5 FLL ee pr CAEL a 871 441 50.6 Bhe MB EONT co vv alinta f siy's maton ee + wate ns 104 47 45.1 Oucentilith ibis) J0/ et oli veld snd dir fain sn eS mwans 174 104 60.9 RICHMONA ss 6 s0tin tr nins s Badia ns s Fah suas e 45 13 33.3 Cases of Poliomyelitis Occurring in 30,575 Babies Enrolled at 59 Baby Health Stations from June 1, 1916, to September 30, 1916. Or THOSE ILL OF THOSE DYING Number —4™M8M8M8 Number —m8m8 mM ——} Reported Breast Bottle Mixed Died Breast Bottle Mixed 111 Fed Fed Fed Fed Fed Fed Under 1 year. . 118 41 : 54 20 36 6 22 8 1-2 years. .... 84 7 28 49 23 ie 4 19 Totals. ... 199 48 82 69 59 6 26 27 Of those ill and fed on bottled milk: Under 1-2 1 Year. Years. 10kcases given Grade A Raw... iin toe ves ve vopnnnivms 9 1 137 cases given Grade -A ‘Pasteurized. ... veins cdisianss 65 72 3 cases. piveniOrade B.c.oh i iaisiaaminess Tamsin vu sito sie 3 —— 135 Of those dying and fed on bottled milk: Under 1-2 1 Year. Years. 0 cases given Grade A Raw.......coevviiiinininininininnn, st oft 49 cases given Grade A Pasteurized...........cooiiiiininnnn. 29 20 2 2 cases given Grade B.....oviiniiiiiiiiiiiniiiiiiiiiiaen, Were the children affected and those dying well nourished or poorly nourished? In how many of the affected families were there more than one child affected? (a) 180 families—1 child—90%. (b) 16 families—2 children—8%:%. (¢) 3 families—3 children—1%5%. What was the sanitary condition of the homes in the affected families? Very good—57; Good—92; Poor—38; Very Bad—12 . In how many of the affected families were screens or mosquito netting used? Yes—113; No—386. Can you state in how many of the deaths there was diarrhoea preceding death? 24. How many cases of poliomyelitis under one year of age, between 1 and 2, and 2 to 6 years of age were listed in your district during this time ? 832 cases under 1 year—17%%. 1,477 cases 1-2 years—31%. 2,448 cases 2 to 6 years—51%%. Total—4,757 How many babies under two years of age were enrolled at your Station during this period—June 1st to September 30th? : 30,575. This tabulation shows that from June 1, 1916, to September 30, 1916, 30,575 babies under two years of age received the advantages of health sta- tion advice and care, and of this number 199 or .65 per cent. were affected with the disease. Of the number affected, namely, 199, 59, or 29 per cent., died. The type of feeding, as noted, shows that babies on breast milk ex- clusively, bottled milk exclusively, or on mixed feeding, and given Grade A raw, Grade A pasteurized, and Grade B milk, were affected and succumbed. Since 99 per cent. of the milk used for the artificial feeding of infants in New York City is pasteurized, it follows that so large a per cent. of the artificially fed children would use pasteurized milk. The fact that only a very small per cent. of the affected ones were fed on proprietary foods bears testimony to the value of the educational campaign waged against these foods by the Department for many years. CHAPTER V. Insects as Carriers of Infection. AN ENTOMOLOGICAL STUDY OF THE 1916 EPIDEMIC.* Early in August work was undertaken under the direction of the Health Department along entomological lines, with the hope that either positive or negative evidence might be obtained bearing on the frequently repeated suggestion that insects of one kind or another play a part in the spread of this disease. This work is so valuable and suggestive that it is given practically as reported. * * * * * * * * * On account of several peculiar facts connected with previous epidemics of poliomyelitis, it has appeared possible that the disease may not be spread directly from one person to another like most acute infectious diseases, but that it may be dependent for its spread upon some intermediate agent, or perhaps upon some other host or living reservoir, or possibly upon a com- bination of the two. The most patent facts which have suggested such hypotheses are those connected with the epidemiology of the disease. Others made known hy laboratory experimentation would seem to show that the disease is passed directly from one affected human individual to another through immediate contact, involving the transfer of the virus from the first person to the nasal passage of the second. That it may be spread through the agency of dust or by various other means has also been sug- gested. The facts which lend color to the belief that insects are concerned are numerous, and some seem to be of considerable importance. Epidemics almost invariably begin during the early part of the summer, in late May or June, reach a climax during early August, then rapidly decline and practically disappear in October. This seasonal incidence corresponds with that of certain diseases known to be insect-borne, and does not occur with other diseases, concerning which we know that insects play no part in their transmission. Certain enteric diseases show a marked summer increase, but they also are partly spread by flies. They never show the almost com- plete winter disappearance exhibited by poliomyelitis in this country. The disease has always been regarded as more abundant under rural conditions, and the present outbreak, although it has occurred in a large city, has not altered this belief, since the Boroughs of Richmond and Queens, the only boroughs which are to any extent rural, have suffered more severely than their heavily populated neighbors. Insects of practically all kinds, except those which depend entirely upon human beings for their existence, are mn-a abundant in proportion to the human population in the country or in * By Prof. Chas. T. Brues, Professor of Economic Entomology, Harvard Uni- versity and temporary Entomologist to the Department of Health, New York City. 137 small towns and villages. Cases of this disease do not usually appear in such a way that they can be positively traced to contact, and many facts con- nected with their spatial distribution, as detailed in the present report, seem to be more easily explicable on the basis of transfer by insects or other ani- mals, or by both. As a result of epidemiological studies undertaken some years ago in Massachusetts (by Brues), it was suggested that the stable-fly (Stomoxys calcitrans) might be the insect agent by means of which polio- myelitis is transmitted. The following year the disease was apparently passed from monkey to monkey by the bites of this fly in two labora- tories. * But these experiments have failed of further confirmation, and cannot now be regarded as free from possible error. As shown later, there is at least one other possible explanation of the epidemiological evidence secured both before and during the present epidemic in New York City. This summer’s outbreak has offered so many opportunities for study that have not previously been available that it is of peculiar interest and value. It has involved a population living under such entirely different conditions from those existing in places where previous epidemiological investigations have been made, that much evidence of an entirely new nature has come to light. On this account, it has been thought advisable to give a brief summary of a number of facts and observations of more or less general nature, before dealing with the matter from a purely entomological standpoint. GENERAL DISTRIBUTION OF CASeEs OF PoLIOMYELITIS IN GREATER NEW York IN REeratioN TO A PossiBLE INsect CARrRIER—Dis- TRIBUTION IN THE BOROUGH OF MANHATTAN. By the middle of September the incidence of poliomyelitis reached a very little over one per thousand of population (1.01) in the Borough of Manhattan, thus falling considerably short of that in Brooklyn and Staten Island, which will be considered separately. A glance at a spot map upon which the Manhattan cases have been marked shows a distribution and abundance which would seem at first glance to correspond quite closely with the general distribution of the human population of the island. On the east side below 34th Street and above Brooklyn Bridge to the east of the Bowery and Third Avenue, there have been a great many cases, and the map is thickly spotted in conformity with the great density of popula- tion in this portion of the City. To the west of this, extending from West Broadway between Canal and 4th Streets northwestward between Bedford at West 4th Street to Grosvenor Street and North River, is another area with a large number of cases. This also corresponds roughly to a heavily populated area, except that this group of cases extends nearer to North * By Rosenau and Brues at the Harvard Medical School in Boston, and by Ander- son and Frost at the Federal Hygienic Laboratory in Washington. 138 River and further south along West Broadway than might be expected on the basis of population. On the middle west side, between West 23d Street and West 32d Street, are a number of well-defined, small foci which do not correspond to a densely populated area. Again, west of Broadway, between 45th and 70th Streets, a great many cases have occurred over a large area which does not support a very dense population. On the upper east side the abundance of the disease corresponds well with the compara- tive density of the population, as there is a large number of cases above 95th Street, the incidence dropping off above 119th Street and 124th Street, in close accord with the density of the population. On the upper west side, between Manhattan Street and West 135th Street, is a large, well-defined focus which does not in any way correspond to a thickly populated area. In general, over the whole Borough of Manhattan the cases have been grouped in a band of varying width, nearly always contiguous to the water fronts of the East and North Rivers, with a narrow portion of the island almost entirely unaffected. This is particularly true south of Central Park, the difference being less marked north of the park. It is thus seen that with some striking exceptions there have been a far greater number of cases per acre in thickly populated areas, with an evident tendency to heavier infection irrespective of density of population along the sides of the island near the water fronts of both the East and North Rivers. When certain areas are examined more in detail, it is seen that they throw further light on the distribution of cases in relation to population and to other possible factors. Lower East Side— The portion of Manhattan east of Catharine Street, the Bowery and Third Avenue south of 14th Street includes a population of over half a million persons. In practically no considerable part of this area does the population fall below 300 persons per acre, and in over half of the acre it ranges from 500 to over 800 persons per acre. Most of the inhabitants are housed in five or six story tenement houses, which line the streets in almost unbroken series. There are large numbers of food-shops and other small stores of various kinds on the street floors of these tenements, and the entire child-population necessarily spends its time upon the streets, the entries to buildings, and the open spaces which serve as back yards to the tenements. Under such conditions it is evident that the opportunities for the spread of contagious diseases must be great, since the number of healthy children that may come in contact with one harboring a contagious disease is greatly enhanced by the congestion of the limited areas in which the children play.* * As the populations of the small areas here referred to have been taken from the census of 1910, figures from the same census have been used for comparison with the city as a whole. The different rates of growth in various parts of the city cannot have been sufficiently different to change the incidence rates appreciably. 139 As has been said, the smaller sections of this east side area represent several distinctly different densities of population, which may be grouped as follows: Area with Over 800 Persons Per Acre. Cases of Rate Area, Population. Poliomyelitis. Per 1,000. SE BCEEE. (vine stimu beteivipinis Sai vs wa 44,500 29 0.6 G10 TACTeR Lis comin vases es ee 37,700 24 0.6 52 acres ii ve sides RE 42,000 30 0.7 POUDY. vse r olin winnie oiain's 124,200 83 .66 rate 0 Per acre 0.55 Area with from 600-799 Persons Per Acre. 7 at SE Age rR ALL (ARCO EP 37,700 32 0.8 A nO RS rr ST salen ee Lk 30,400 16 0.5 40 Acres” J. i A EE ee es sae 25,100 19 0.7 36.0018 2un ivi vs per Fe 23,100 18 0.7 Batali en 116,300 85 0.73 rate Per acre 0.48 Area with from 500-599 Persons Per Acre. 28,600 18 0.6 34.900 66 1.9 22,800 25 1.1 25,700 43 1.7 23,500 31 1.3 135,500 183 1.35 rate Per acre 0.74 Area with from 400-499 Persons Per Acre. } BR ACTOR: ch cnnmaani es pa rae s Th 3 we 24,400 43 1.7 52 aLYeS i its i ES RS Seat ah Senile 25,700 22 0.8 A3 ACTBE. cu covitvninio vias saunas 4 van atxiniuie 18,800 2) 1.1 BT ACTOR tinh voninlnin vies mablvraiisie v4 Fre Ts 25,500 15 0.6 30. TACTES 5 chine ch iment» 90 prietngs 16,300 16 1.0 ES nErEE ou cbs deniers be aerials ee 27,100 42 1.5 TOL, cts stones 137,800 159 1.15; rate Per acre 0.53 Area with from 100-135 Persons Per Acre. AT RCTS 4. a Lhe Ae Sy ve de A ie 5,600 6 1.0 - rate Per acre 0.13 From this table it will be seen the area of densest population has had a very decidedly lower incidence than any of the more thinly populated sections in this part of the City. As a matter of fact, the highest incidence has been in the group of 500-599 persons per acre, although this group has not had a noticeably greater incidence except in one small part than the group of 400-499 persons per acre. Thus the only direct relation of density of population to incidence of poliomyelitis has been an inverse one in this district, if the incidence be related to density at all, and this agrees with the general tendency noted elsewhere for sparsely settled regions to be more severely affected. If in this same district, we compare the incidence with the area, i. @., the incidence per acre, we find that it is more nearly uniform than it is in Li f 140 relation to human population (with the exception of one small area with only 115 persons to the acre), since this incidence varies only from .48 to 74 per acre. This is suggestive of the possibility that some other popula- tion than the human one may take part in determining the incidence of the disease in children. With this in mind, if we compare the incidence in the densely populated sections (see Map 1) contiguous to the water front with the remaining sections, we find that it is as follows: Cases of Incidence Incidence Poliomyelitis. Population. Per 1,000. Acres. Per Acre. (Tont'quous to water front 213 145,400 1.46 313 .68 Removed from water front 318 388,300 0.81 615 51 This indicates that the incidence has been much higher along the water front, both in relation to population and in relation to the actual area of the sections, corroborating the general impression that there has been a well-marked tendency for the cases to group themselves along the water front throughout the City. In this particular instance none of the sections are far removed from the docks which line the river, although the strip selected for comparison lies directly adjacent to the water while the others do not. This grouping is also suggestive of a factor aside from human population and social conditions. It is at least not contrary, but is what might be expected if the rat should bear some relation to poliomyelitis, and might possibly be explained on such an hypothesis. On the other hand, for no reason which seems apparent, the three sec- tions (see Map 1) which mark the northern limit of the thickly populated district between 9th and 14th Streets, all have a very high incidence : (Cases Incidence of Poliomyelitis. Population. Per 1,000 Acres. Incidence Per Acre. 85 68,000 1.23 129 .66 It does not equal that of the sections along the water front, but is, nevertheless, far in excess of the other sections removed from the water front. Whether this strip supports a larger rat population than its neigh- bors on the south would be difficult to say. In so far as insects of any kind are concerned, it seems impossible to understand the peculiar distribution of poliomyelitis in this district on the basis of their comparative abundance. It is true that the stable fly is especially abundant along the water front on account of the large amount of trucking which goes on there, but it is not noticeable that the disease has spread along the streets which are most generally used for teams. The disease should follow these streets if the stable fly were concerned, as this insect migrates most abundantly along thoroughfares through which many horses pass regularly. That it has not followed these streets would therefore seem to be significant, especially in 141 view of its greater prevalence along the northern strip of this district where there is no more traffic than in the other portions further south. One fact which seems perfectly clear is, that under urban conditions of this type where large numbers of persons are crowded in congested dwellings, there is no tendency toward a rise in the incidence of poliomyelitis. This is abundantly shown by the details which have been cited in the preceding pages, and offers poor support to the view that these cases have been con- tracted as a result of contact with children suffering from the disease, or as a result of contact with healthy carriers of the poliomyelitis virus. Lower West Side— Considerable interest attaches to a small group of cases on and about Greenwich Street just north of Battery Park. Only about a dozen of cases have appeared here, the first during the last week in July, and the others in irregular sequence during August into September. This focus has remained entirely isolated from any others, although it is not separated from them by a space devoid of dwelling houses. Its direct connection with a large focus near the West 132d Street docks is, however, evident since there are boats plying daily between these uptown docks and those directly adjacent to the Greenwich Street focus. These boats might easily serve for a transferance of rats, but their passengers come from widely separated parts of the City, and not particularly from affected regions about Green- wich Street or West 132d Street. Middle West Side— Although the area to the south of West 33d Street and West of Sixth Avenue has not suffered severely, it shows a very interesting distribution of cases into several small, well-defined, and more or less isolated foci, each of whieh includes only a few cases restricted to a single block or to two adjacent ones. The grouping and form of these very small foci is of such particular interest that it is dealt with on another page. Further uptown there is a noticeable concentration of cases in the district adjoining the stock yards in the vicinity of West 68th Street. This group is quite discrete, but the cases are not so closely associated as in a number of other districts. As the group is in proximity to the stock yards, there is here an especially great opportunity for both rats and the various bloodsucking flies, such as the stable fly and the members of the genus Tabanus, which are associated with the larger domesticated animals. Upper West Side— An extremely interesting group of cases has developed near North River between West 126th Street and West 142d Street, most concentrated (see Map 2) between West 130th Street and West 132d Street. In this area by the middle of September 42 cases had appeared and later several more had been reported. The density of the population is very much less 142 than in the district on the lower East Side, which had been referred to on a previous page. It ranges from 83-140 persons per acre, with an incidence of poliomyelitis of from 0.8 to 3.6 per thousand of population, as shown in the following table: ] Density Per. Number Rate Rate Area. Population. Acre of Cases. Per 1,000. Per Acre. d7Eacres ie. aiid 3,900 83 8 20 a7 B00acres ...icevin nnn 6,800 137 25 3.6 .50 47 acTes usin 3,500 176 3 0.8 .06 470aCTeS. o.oo ddan 6,600 140 6 0.9 a2 Total’. ...0 0 va 208007 ese 42 2.0 22 It thus appears that the incidence in this area of comparatively sparse population has greatly exceeded that on the lower East Side, being as a matter of fact almost double, showing again very evidently that maximum incidence under these quite urban conditions is not a function of the popu- lation density. The same fact is, of course, evident by the very irregular distribution of cases in practically every locality affected, but on account of the great number of factors which may be involved, it is difficult to draw conclusions from this. It may be said, however, that it does not accord well with what might be expected if some actively flying insect were con- cerned in the dissemination of poliomyelitis. It does resemble at first blush foci which have developed in the City as a result of carrier typhoid infec- tion, but many of these poliomyelitis foci cannot be associated with any probable carrier, and besides, the distribution of the whole epidemic corre- sponds in no way to that of typhoid. This matter is dealt with on another page. There have been other smaller, and a number of larger, sparse groups of cases in Manhattan, but most of them do not show a sufficient size or concentration to make it evident that they represent really definite differ- ences in incidence. Irregular population distribution and many minor factors might so easily account for them that they can hardly form the basis for generalizations. Distribution in the Borough of The Bronx— The number of cases in The Bronx has been comparatively few and the incidence correspondingly much lower than that in other boroughs. There have been no foci of any considerable size or density, although earlier in the course of the epidemic it seemed probable that several were de- veloping. These proved to be evanescent, however, and later cases have produced a quite even distribution over the area north of the Harlem Riv, and between the line of the New York Central on the west and the New York, New Haven and Hartford on the east as far north as Bronx Park and Fordham University. Along its western boundary this area has ex- 143 tended a short distance west of the railroad, but the western part of The Bronx has been practically free from infection—in fact remained almost entirely so until very late in the course of the epidemic. This western section is very much more sparsely settled than the eastern one which suf- fered from poliomyelitis, and is quite generally separated from it by much nearly vacant land. Nevertheless, it has continual intercourse with the City. We could find no lack of insects in this district—in fact conditions are favorable for the production of our common bloodsucking flies. The land is considerably elevated and thus well separated from the railroad that skirts the Harlem River Canal. It would, therefore, appear unlikely for rats to reach it from the railroad on account of its sharp elevation on this side. Also, the region is devoted almost exclusively to the homes of the well-to-do, who remove their children from the City for the entire summer. Distribution in the Borough of Brooklyn— Since the present epidemic first gained serious proportions in Brooklyn, especial interest naturally centres upon its behavior in this borough. The incidence has been considerably over twice that for Manhattan, and the disease has appeared abundantly in districts of several types. As it has also showed a more or less constant movement or shifting from the first centre, the course of the disease in Brooklyn offers much valuable infor- mation. In the immediate vicinity of its origin in Brooklyn, the epidemic did not gain the intensity which it showed some time later in adjoining districts into which it had spread in the meantime. There has been, however, a great number of cases in the district into which the northern end of the Gowanus Canal extends, an area which is roughly coincident with the first indications of an epidemic. Here the greatest number of cases have appeared in the district west of Third Avenue, north of Third Street and south of Wyckoff Avenue. They have extended to the East River in decreased numbers over a narrow space, and then in greatly increased abundance along the region adjoining the water front from Joralemon Street to Hamilton Avenue. This portion of Brooklyn is rather thickly settled, but the dwellings are to a great extent old wooden houses that do not contain a great number of families. On the whole, it is eminently suited to support a large population of rats and a considerable one of house flies and stable flies, the former on account of its proximity to the water front, its old houses, and the latter also by reason of its numerous stables. On the whole, the sanitary conditions under which its inhabitants live are bad, partly from necessity due to the surroundings and partly from lack of desire for cleanliness. To the south of this part of the borough, and separated by a narrow strip, is another area in which a great number of cases have occurred. This follows quite closely along the water front and extends as far as 60th Street, with only one or two insignificant breaks. The northern part of 144 this area is composed of blocks which contain tenements that house a large number of families, and consequently this part has had more cases in pro- portion to its area than the part further south, which includes a great number of smaller houses. These smaller houses are in many cases old wooden buildings, but many are of far better stone and brick construction, although nearly all were built many years ago. A few newer apartment buildings of small or moderate size are scattered through this southern part of the district. Although of far better appearance in nearly every respect, much poliomyelitis has appeared here. It has undoubtedly shown a prefer- ence for the older wooden houses but has nevertheless occurred quite com- monly in the neatest of the small brownstone and brick houses. On the whole, the probability of a considerable rat population here would seem less likely than in almost any other part of the City in which poliomyelitis has appeared abundantly. In proportion to its resident population, Coney Island, which forms the southern end of Brooklyn, has suffered quite heavily. Here there have been two more or less clearly defined foci with a few more scattered cases. The greater part of these has been in old houses under bad sanitary conditions, and neither rodents, flies or insects would be excluded. The most extensive group of cases in Brooklyn was in an irregular area. The upper arm extends from East River between the Williamsburg Bridge and Greenpoint Park eastward to somewhat beyond Myrtle Avenue. The lower arm drops considerably to the south of Myrtle Avenue as it approaches the west and stops short just before reaching the Navy Yard. The whole group is more or less distinctly separated from the foci further south, but is connected by a narrow group that extends along the southern boundary of the Navy Yard, and then suddenly enlarges to occupy a con- siderable area about the approaches to the Brooklyn and Manhattan Bridges. Below this, however, there is a distinct break of fully a quarter of a mile before the limits of the first Brooklyn area mentioned is reached. The space between the arms of the above-mentioned include the area bounded by Division Avenue, Broadway, Wallabout Street and the Navy Yard. Within this space only a comparatively few scattered cases have occurred. This section includes much of the older, more thickly settled portions of Brooklyn, and supports a rather uniformly dense population. The incidence of poliomyelitis has been very high, much higher than in the densely popu- lated sections of the lower East Side in Manhattan, although the inhabitants do not live under such conditions of congestion as their neighbors across the river. The last distinct group in Brooklyn to be mentioned is one which em- braces the Hebrew section commonly known as Brownsville. Here the incidence has not been so high as might have been expected from the con- ditions which prevail. The population is sparser than in the last-mentioned section, but not sufficiently so to account for the great scattering of the 145 cases. This group is quite sharply limited to the north by Atlantic Avenue, for above this, in the better section, a smaller number of cases have occurred.* From this it can be seen that the distribution of the cases in Brooklyn has been apparently much more erratic than in Manhattan. Practically all of the water front which supports large shipping activities has had a dense fringe of cases in the residential blocks that extend inland. In this respect it has shown a more or less close agreement with Manhattan. About Gowanus Canal the district affected has extended inward further, possibly through some influence exerted by the canal. The large area northeast of the Navy Yard adjoins the water only for a very small part of its extent, and extends inland over an area of closely built-up blocks of mainly old houses. In Brownsville far removed from the water front the incidence has been lower than might otherwise has been expected, from comparison with other parts of Brooklyn. On account of its strict adherence to the environmental conditions mentioned, it seems evident that the method of propagation, if it be other than chance contact of individuals, must depend upon something correlated with such conditions. The proximity of so many affected areas to the water front, the exceptions being in two closely populated districts of which the one farther removed from the water front suffered less than was expected from living conditions, both point to some population other than the human one. No insect which I have observed abundantly seems to fulfill these conditions, although the epidemiological conditions, including the spread in the Brooklyn areas, would seem to be explicable with little difficulty by rat prevalence and migration. Distribution in the Borough of Richmond— Staten Island, the least urban of the Boroughs of Greater New York, has suffered very severely from poliomyelitis during the present outbreak. With a population of less than 100,000 persons and over 290 cases, the incidence has been approximately 3 per thousand. This is particularly inter- esting since it gives an opportunity to compare the same epidemic under conditions prevailing in the lower East Side, probably the most congested district in the world, with Staten Island, a small city with attendant villages and countryside. The triply greater incidence in Staten Island bears our previous experience that poliomyelitis is a rural disease, more prevalent in thinly settled districts than in cities. This fact of course suggests, as it has in other parts of our own country and abroad, that the dissemination of the infective virus is dependent upon some insect or other animal popu- lation which is uniformly more abundant in proportion to the human population under rural conditions than it is in cities. An examination of the island from an entomological standpoint has unfortunately failed to disclose much further information of apparent value. The cases are grouped into what may be conveniently classed as four types. Many are * Brownsville was infected in the previous epidemic of 1907. 146 in the older and more thickly settled parts of the island. They have been as a rule in the poorer sections and streets and along the water front, the latter in this case contiguous to the most thickly settled parts. Others have been in suburban residence districts of well-built, well-kept and separated houses. Others have been scattered throughout the thinly settled parts of the island, usually along or not far removed from the main thoroughfares which traverse it. A few have been at summer camps where large numbers of city people are crowded together in small one or two room tent houses or “bungalows.” These camp houses have been comparatively free from poliomyelitis, considering their quite considerable population. They are built directly upon the sandy beaches, very generally raised from the ground by wooden blocks or short pillars, and this, in connection with the fact that these camps are vacant during the winter, rfiust reduce the rat population very greatly. If this condition be compared with that in the section of Coney Island which has suffered, it is seen that prevalence of rats is evi- dently in these two cases parallel with that of poliomyelitis. In the two places flies of the common kinds do not appear to be noticeably different in abundance. The general distribution in Staten Island is so similar to that already observed during many epidemics in small cities with their surrounding vil- lages and scattering houses, that I have been unable to find any striking peculiarities. Some cases have been almost entirely isolated, but in many instances there have been groups of two or three nearly simultaneous cases. Some of these have been in single houses or families, 21 secondary and tertiary cases in all, or over 7 per cent. of the total 290 cases. This per- centage of secondary cases in Staten Island is at least double that in Greater New York as a whole and is difficult to understand on the basis of infection from person to person, since there cannot be twice the opportunity for such contact in Staten Island. This excess should be anticipated, however, in the case of transmission by insects infected from a non-human host, if their population is greater in proportion to the human population. It would result in a greater number of infective agents at work among a smaller number of persons, so grouped that the houses or family stands out as a definite spatial group liable to multiple infection. Such house or family isolation of this type does not occur in the other boroughs to any extent. and we do not find so many double or triple cases in them. The other groups of two or three cases, mentioned above as near together but not in the same house, have appeared in a number of more or less isolated spots on the island. They would appear to be homologous to the similar pairs or small groups that are continually cropping out in the thickly settled boroughs, due apparently to the appearance of some infective agent. The distance traveled by the agent cannot be traced under the com- plicated conditions prevailing in the other boroughs, but in Richmond, as in other sparsely settled districts, the distance possible in a short space of 147 time is evidently at least several miles. This is, of course, easily explained either by the possible advent of a human carrier, or by the appearance of some insect or rodent, since the same method of spread has been observed with yellow fever and bubonic plague when they have spread by introduc- tion into places where they are not endemic.* As the Staten Island outbreak is being very carefully studied and tabu- lated by others, their findings may show that some of my own brief observa- tions have been misleading. At any rate the behavior of the disease on Staten Island has been surprisingly like its previous behavior in other small cities, and the divergencies which appear between this borough and the others of Greater New York consequently become of enhanced value. Distribution in the Borough of Queens— The entomologist has not given much attention to this borough, partly as it did not seem to exhibit conditions strikingly diflerent from those observed in other parts of the City and partly because of the impossibility of covering such a large area with any degree of completeness in the limited time available. One well-defined focus of about twenty cases in Long Island City was visited. This locality is very much like those re- ferred to in the Borough of Brooklyn, in the region of the Gowanus Canal. It is directly on the water front, adjacent to the yards of the Long Island Railroad, and near Newtown Creek. The area occupied is very closely isolated from any other focus, and the cases appeared over a considerable period during July and early August. Over half (11 cases), however, were reported during a single week following the middle of July. The course of cases in this focus has followed the usual rule observed in others; an isolated case, one or two more coincident or a few days later, after a couple of weeks a considerable proportion of the entire number, then a gradually dwindling scattering of cases. One other locality in the Borough of Queens which suffered rather heavily was the extensive summer colony which extends along Rockaway Beach. Many cases appeared here in three or four poorly defined groups. Here the conditions are similar to those of Coney Island except that the houses are of better construction and in somewhat better condition. They are, however, old and not of the small type with open-air space below men- tioned in connection with Staten Island. Distribution Summarized— In reviewing the material presented in the present section of this report the following facts seem worthy of repetition: In general the cases of poliomyelitis have grouped themselves more or less in proportion to varying density of population in different portions of * A small epidemic of yellow fever on the Island of Barbadoes described by Boyce, and several small outbreaks of plague in Sydney, N. S. W,, are extremely interesting in comparison with the present poliomyelitis epidemic in Staten Island. 148 the various boroughs. © There has nevertheless been a distinct tendency toward a higher incidence in sections directly adjoining Brooklyn. Great density of population does not tend toward a higher incidence of the disease. This is shown particularly from a comparison of the East Side tenement section with other parts of Manhattan. Numerous areas have been practically free from infection, while others of apparently similar character and human population have developed extensive foci of poliomyelitis. Staten Island has suffered more severely than any other borough except Queens, showing the usual tendency of poliomyelitis to affect rural districts more heavily than cities. The high incidence in Queens was reached during the last weeks of the epidemic, as the disease spread to the more thinly populated sections. Many facts of distribution and general prevalence suggest that the disease is at least to some extent dependent upon some population other than the human one for its spread. Insects migrating by themselves, or on the body of some animal host like a rat, might easily account for the facts dealt with in this section of the report. DisTRIBUTION OF CASES IN RELATION TO THE IMMEDIATE NEIGHBORHOOD. In referring to the general proportions of the epidemic in the several boroughs, and in the smaller areas where definite foci have developed, it has been impossible to deal with a great many facts which have a bearing on the possible relation of insects to the spread of poliomyelitis. Some of these may be conveniently discussed separately. The Grouping of Cases in City Blocks— The completed block in a city forms a more or less definite entity, which differs in many respects from a mere aggregation of dwellings. It is com- pletely walled in on its four external sides and usually encloses a large com- mon space which is divided into yards apportioned to the dwellings. Over quite a considerable part of the areas of Manhattan, Brooklyn and The Bronx where poliomyelitis has been prevalent, the dwellings form entirely, or almost entirely, completed blocks of this kind. When districts of this kind are plotted for poliomyelitis, it is seen that the distribution of cases is by no means regular; such could hardly be ex- pected with so few cases occurring over a small area. There is shown, how- ever, quite a distinct tendency for the cases to group themselves more or less definitely in certain blocks while others of similar construction, and supporting a similar population, remain entirely free from the disease. This tendency is well illustrated by several maps (pp. 165-169) taken from a dis- trict on the middle west side of Manhattan where there have been a number of small foci of the disease. In the first map (A), two adjacent city blocks are seen to be heavily infected, having seven and eleven cases respectively, 149 divided between two sides of each block, while the contiguous ones have entirely escaped as indicated. In another group (B), one block has suffered seven cases, while in the adjacent blocks only a single one appears across the street from the group of seven. In the third group (C), one block con- tains five cases, occurring on both sides of the block, while the adjacent ones are free from the disease. In this same small area, three cases appear along the northern side of the lowest block, but none across the street. In the fourth group one block contains six cases, distributed along one side, while the adjacent one has three, only one of which apparently bears any relation to those across the street. It is not easy to put such data upon a statistical basis, but so many groupings like those figured have occurred that it does not seem possible to ascribe them to chance. It is very evident that they do not correspond with the more common movements of children which would bring them into contact with other children. Such association in playing is more apt to happen between neighbors across the street than it is with those living down the block, around the corner or on the next street (of Fig. 1-A). Tt is also not easy to believe that any human carrier or any flying insects would show the type of movement or migration necessary to produce case distri- bution of this kind. It is, however, easier to believe that rats, or even domes- tic cats might easily migrate in this fashion by the way of yards or back fences. It may be mentioned here that dogs are not generally present in the tenement house districts. These maps bring out another interesting fact. It will be seen that in the few blocks represented, five houses have had more than one case (4 houses with 2 and one with 3). Multiple cases almost invariably occur in blocks with other cases; that is to say, it is very unusual to find two cases in a single house or family without additional cases somewhere else in the block. We thus see that there is a tendency for certain blocks to become centres of infection, and that the chances of second cases appearing in families is enhanced by, and seems almost dependent upon, the presence of other cases in the block. This, coupled with the entire absence of the dis- ease in so many blocks adjacent to infected ones is hard to understand on the basis of a healthy human carrier or of flying insects. Since a large part of the cases of poliomyelitis have occurred in blocks that are used exclusively for dwellings, it has been possible to observe what relation stores, stables, etc., may bear to individual cases. This cannot be satisfactorily tabulated on account of the almost innumerable degree of asso- ciation with one type or another of food-shop, market, delicatessen, restau- rant, bakery, stable, etc., and we have had to rely on impressions gained during the examinations of districts, supplemented by notes made concerning 150 individual cases. The following list is typical of one of the somewhat better districts where there has been a group of scattered cases in The Bronx. Poultry and meat market in building (Tenement) .* Candy store next door (Tenement). Poultry and meat market in building (Tenement). No shops or stables (124 story old wooden building). No shops or stables (Tenement). Stable next door (2 story old wooden house). No shops or stable (old 3 story brick house). Grocery, candy store, laundry in building (Tenement). No shops or stable (Tenement). Bakery and lunch room next door (old 3 story wooden house). Grocery and dairy in building, candy and ice cream store next door (Tenement). Bakery next door (Tenement). A second area in Manhattan was as follows: Case. 1. Case 2 Case 3 . Case 4 Case 5. Case 6. Case 7 Case 8 Case 9. Case 10. Case 11. Case 12. Case. 1. Case 2. Case © 3. Case 4 Case 5. Case 6. Case 7. Case 8. Case 9. Case 10. Case 11. Case 12. Case 13. Case 14. Case 15. Case 16. Case 17. Case 18. No shops or stable (Tenement). Over delicatessen shop, stable 2 doors away (Tenement). Over stable (brick house). Over ice cream store, macaroni factory next door (Tene- ment). g Delicatessen store next door (Tenement). Over junk shop, grocery next door (Tenement). Grocery on one side, saloon on other, with meat market next (Tenement). Over vacant basement grocery, basement grocery next door (Tenement). Vegetable store in one half of basement, grocery in other (Tenement). No shops or stable (Tenement). No shops (Tenement). Over meat market, adjoining buildings not dwellings (Tene- ment). Over meat and provision store, “ Pork” store next door (Tenement). No shops nearer than market two doors away (Tenement). Over undertaker’s shop (Tenement). No shops or stable (Tenement). No shops or stable (Tenement). Grocery next door (Tenement). * The word tenement is used only for large buildings of four to six stories, each housing numerous families. 151 There seems to be a well marked tendency for cases in Manhattan to appear in the immediate vicinity of stables, groceries, meat or poultry mar- kets, lunch rooms, delicatessen shops and bakeries or macaroni factories. The kind of stores vary, of course, with the neighborhood, and some of the sorts mentioned do not occur in every district. However, it is surprising with what regularity one or the other is found in the building or next door to a house in which poliomyelitis has occurred. Others who have also examined the same districts with an unbiased mind, seem always to believe that cases range themselves with a definite relation to shops of this type. It has been repeatedly pointed out in earlier epidemics that stables are often associated with cases of poliomyelitis. This has been undoubtedly true in New York during the present summer, but the other association with pro- vision shops has also forced itself upon our attention. In combination with other observations, the present ones are interest- ing. Association with stables at one time appeared suggestive in connection with the fact that stable flies might be the carrier of poliomyelitis. Stables support rats as well as stable flies, and as food shops support the former, but not the latter, this is another bit of evidence pointing toward the rat, or perhaps the domestic cat, as these animals are maintained in particularly great abundance in shops of the kind under consideration. It is a generally accepted idea that the presence of cats serves to keep buildings free from rats. This is erroneous as has been abundantly shown by various observers who have found rats and cats commonly occurring together, both in build- ings and on shipboard. In more or less close connection with this matter, there is another which is brought out in our notes taken of individual houses. In the table given on page 150 it will be noted that several cases occurred in wooden buildings. It happens in this district that these buildings scattered among blocks of tenements are relics of a period before the neighborhood was engulfed by the City. These buildings house an insignificant number of persons com- pared to the tenements, yet they have suffered considerably from polio- myelitis. This is only an isolated example, but is typical of the fact that so far as one can form an opinion by careful observation and reflection, it is the older or more poorly cared for, particularly wooden houses without cemented basements, which suffer most severely. Thus, the house next door, is so frequently found to be at least noticeably better than the infected one, either newer, of better construction, kept in a more cleanly condition, or in better general repair. There are, of course, exceptions, many due as nearly as one can tell to the association with shops mentioned above. In certain parts of Brooklyn, where houses of different ages and types of con- struction are grouped together, examples of this kind have been especially striking, but it must be repeated that exceptions are by no means uncommon. The Grouping of Cases in Individual Houses— In going over areas where poliomyelitis has occurred in the City, one gains the impression that there is a tendency for the cases to be more 152 abundant on the lower floors of buildings. It has been possible to examine this matter statistically, and also to compare the distribution of poliomyelitis with scarlet fever and diphtheria in this respect. For this purpose, the Borough of Manhattan was selected since only a negligible percentage of the buildings used as dwellings are less than four stories in height. The vast majority of the population is housed in buildings of four and five stories, so that the number of cases occurring on the various floors, should show whether the incidence of the disease really bears a relation to the floor upon which the families live. For a check, two diseases, scarlet fever and diphtheria, known to be spread by personal contact and to some extent by apparently healthy car- riers were chosen. The way in which these latter two diseases are appor- tioned to the various floors of dwellings in Manhattan during the late Spring and early Summer of 1916, and the distribution of poliomyelitis during the epidemic, is shown on the accompanying charts (pages 171 and 173). These data are somewhat difficult to interpret as in a number of cases the floor is given as “ top ” instead of by number. Some facts are, however, clearly evident. On the first floor, there are fewer cases than on the second and third floors, as quite frequently there are stores or places of business on this floor, which reduce the number of available dwelling places. It is seen that 17.9 per cent. of the cases of poliomyelitis were on the first floor, against 12.9 and 11.8 for diphtheria and scarlet fever respectively. On the basement, first, and second floors together, the number of cases of polio- myelitis has been greater and on the third and higher floors together it has been lower, than in the case of either diphtheria or scarlet fever, as is shown in the following table taken from the chart. A very few cases on higher floors and in private houses are omitted ; they amount to only 19, of the entire totals. Basement, 1st and 2nd Floors. Third and Higher Floors. Poliomyelitis .......c...cvonnn.. 44.3% Poliomyelitis w.:i. toon dinate 54.1% Diphthesia to. 0 00 osesbondde es oe 39.9% Diphtheria. i. comshvisnns sen aihn 58.9% Scarlet Fever .......cssvves tris 37.0% Scarlet Fever ......vvvvvvunvnn 60.5% In Brooklyn there appears to have been an even greater tendency for the cases of poliomyelitis to be more abundant on the lower floors of dwell- ings (page 175). Here, however, on account of the number of buildings of only two stories, it is impossible to make a dogmatic statement. It can be seen that poliomyelitis has been consistently more abundant on the first two floors, and less abundant on the higher ones. This difference implies an infective agent which is more prevalent near the ground; the only other plausible assumption would seem to be that the disease is favored more by the lack of air and light on lower floors than are scarlet fever and diphtheria. This greater prevalence on lower floors is also easily explained by an insect carrier such as various flies and mosquitoes, or by an associa- tion with rats or cats. In the case of the rat it would seem that the differ- ence should be more marked. This, however, is only an opinion, not based 153 on actual facts. Rats do commonly occur on the upper floors of buildings, but presumably in lesser abundance than on the lower ones. In this con- nection it is noticeable than in children under one year old, at which age it is probable that they play more regularly in the apartment in which they live, the divergence between cases occurring on lower floors and upper ones is greater than in older children, who, it may be expected, spend more of their time down stairs or on the street. The following table illustrates this point: Age Under1 Yr. AgeOver5 Yrs. Basement, 1st and 2d Floors... . «cosas ssanisisis 49.3 44.8 Third Floor and above. ou.v. »svivine va ssr sania 50.6 53.2 Number (Of Cases. v0. ona dies sa hnasisss veniirns 227 301 In over 500 cases about which data is available, there is a difference of 5% in the number of cases occurring in the lower and upper division of buildings, when we compare very young children and those of considerable age. This is additional evidence that there is actually a selection of lower floors and that this selection is due to the failure of the infective agent to attain the equal prevalence on higher floors.* Houses in Which More Than One Case Has Developed— Some very interesting data which bear upon the possibility of insect transmission are brought out by an examination of the distribution and sequence of the cases in houses and in families where more than a single case has occurred. The number of such instances is smaller than happens with most of the acute infectious diseases of childhood. This fact may be satisfactorily explained in several ways, and in itself furnishes no evidence of value. The greatest number of additional cases which occurred in families have had an onset coincident with that of the first, and the number of addi- tional cases has decreased almost uniformly from day to day until after a fortnight a second case almost never appeared. This may have been due to the quarantine measures adopted, which have usually included the removal of the patient to a hospital. In fact the same behavior is shown by scarlet fever, which, together with poliomyelitis is graphically represented on the accompanying chart (Fig. 5). That this may not be true, however, is sug- gested by the fact that the appearance of the later cases in the same house, but not in the same family does not follow the same curve, but that with the exception of a single drop on the third day, it has dropped much more gradually. Another noteworthy fact is that the number of cases appearing in the same building, but in another family or apartment, is far greater in this epidemic of poliomyelitis than has occurred in 1916 with either scarlet fever or diphtheria. The latter disease has not been included on the chart, but the following table shows the apportionment of later cases by houses and families for the three diseases. * This study is incomplete and the conclusion therefore not fully justified owing to the fact that no count was made of the children of the specially susceptible ages, or the children of all ages living in apartments on the various floors of the tenements. It cannot be safely assumed that there is an equal distribution of children of all age groups on the different floors of the tenements in New York City.—[Editor’s Note.] 154 Cases in Cases in Same House But Same Family. In Different Family. Polomyelitis ..civiiziivivmuenineisssniven 335 or 56% 257 or 43% Scarlet Fever’ cu... .creiinsansior mnsmnnes 198 or 86% 31 or 13% DIDALAEEIR .....vuvnasrivrsnndrsssninnsives 73 or 78% 20 or 21% It is evident that there is a very great difference between poliomyelitis and the other two diseases in the number of later cases that have appeared in the same building, but in a different family. Thus 439 of the additional cases or early half appeared in the same house, but outside the family in which the original case occurred. This is more than double the number (219%) for diphtheria and more than treble (13%) the number for scarlet fever. It seems incredible that such a divergence should exist if poliomyeli- tis like the others were spread through infection from sick individuals or healthy carriers, and the susceptibility of the exposed individuals is the same. The gradual dropping off of additional cases from day to day and the large proportion of cases occurring in other families in the house may be easily explained on the basis of the appearance of some non-human popu- lation in the house, not definitely restricted by the boundaries which prevent intimate association, followed by its actual disappearance or inability to cause infection after a variable length of time. So far as this evidence is concerned, this population might be composed either of insects or of higher animals such as rodents or cats. Insects as Possible Carriers of Poliomyelitis— As has been pointed out on the preceding pages, many facts in the epi- demiology of poliomyelitis seem to show the spread of the disease to be such that it is impossible to understand its distribution without assuming either a migrating, i.e., healthy human carrier, or a migrating non-human carrier, either an insect or another animal, perhaps both. Aside from possible spread through numerous healthy adult human carriers no carefully considered hypothesis has been advanced which does not include some insect in the role of a casual or specific carrier. There is much experimental evidence in support of the idea of contact. Thus, it has been shown that the virus of poliomyelitis can be recovered from the mouth, nose and intestines in sufficient quantity and in such con- ditions that it is capable of causing the infection of monkeys upon intra- cerebral inoculation. This recovery of the virus has actually been made, from apparently healthy persons who have been in contact with children ill with poliomyelitis. After this virus has multiplied in the central nervous system of the monkey thus infected, it is capable of infecting another monkey when implanted upon the mucous membrane of the nose. This of course suggects that human cases may result from infective nasal or buccal dis- charges, not gaining access to the brain directly, but through the nasal mucosa. While suggestive, this evidence is not conclusive for it is quite 155 probable that the same procedure could be followed with the virus of rabies secured from a person afflicted with the disease. Other experimental ob- servations upon monkeys have shown that the quantity of poliomyelitis virus present in the blood during early stages of the disease is very minute, and that considerable quantities of blood are required to reproduce the disease in another monkey. This would suggest that infection was not secured from the blood, or that if it were, an insect acting as a biological carrier and not as a mechanical one should be involved. That the virus is not more abundant in the blood of human cases in the early stages of the disease than it is in monkeys would seem probable, although by no means proved, since the ex- perimental transfer from one animal to another is accomplished by use of portions of the infected spinal cord, and departs so widely from what must normally occur that it is possible that stages of invasion in which the blood stream plays a part may be entirely eliminated by the present laboratory methods. It is quite possible that the virus might be obtained by a blood-sucking insect from the superficial nerves, some of which are commonly reached by the mouth parts at the time of the biting. Similarly, inoculation into these nerves could easily occur at the time of a later feeding by the insect. As already mentioned, the evidence that insects are a factor in the spread of poliomyelitis is based to a great extent upon epidemiological evi- dence. Aside from facts of general application referred to in the introduc- tory part of the report, the present epidemic has offered an opportunity to examine the spread of the disease in a totally different environment from those in which it has previously been studied. Such facts and observations have already been given as seem to bear on insects, but attention has been called to only a few ways in which they may be applied to the purpose of the present investigation. No attempt has been made to conduct an actual census of the insects present in houses or apartments where poliomyelitis has occurred, as it did not seem that such a procedure would lead to satis- factory results. It is apparent that a disease so common as poliomyelitis, if dependent upon an insect, must depend upon some abundant species. That any insect occurring in sufficient abundance to account for cases over large areas should be absent in others does not seem probable, and is not in agree- ment with what is known to occur in the case of other insect-borne diseases. With yellow-fever, for example, the yellow-fever mosquito (aédes) regu- larly occurs over large areas (e.g. “the southern United States) where the disease does not exist, and it is also regularly distributed in all parts of a city (e.g., Guayaquil, Ecuador), while the cases of yellow-fever occur in such a way that the comparative abundance of mosquitoes does not show a definite correlation with the number of infected ones. Such is also the case with bubonic plague, although here the greater abundance of the disease in parts of a city heavily infested with rats is evident when a number of areas are examined for rat prevalence. For this reason no census of houses has been taken in studying the present outbreak of poliomyelitis, but many cir- 156 cumscribed areas have been examined for the general type of insect fauna existing there. There are three types of insects which are suited by their habits and association with man to act as carriers of human infectious diseases. One type includes such insects as lice and bedbugs. The first are epizoic para- sites during their entire life and do not commonly pass from one individual to another except during close personal contact. They do not remain alive for any length of time away from their host. Such insects obviously cannot account for the spread of poliomyelitis since cases continually come to notice where a transfer of lice could not have occurred. In fact this commonly is more difficult than the transfer of infection by droplet contagion. A louse- borne disease like typhus fever also shows an entirely different epidemiology from poliomyelitis. The bedbug is less dependent upon its host as it can live for long periods without food and may thus easily change its host. How- ever, it does not commonly migrate on its host, nor probably to any extent through tenement buildings except when impelled by the continued vacancy of apartments. It lives almost entirely on human blood and thus does not migrate on the bodies of animals. Extensive migration of such kinds as would be necessary if it were an active agent in the spread of poliomyelitis, even under conditions existing in the crowded sections of New York seem utterly improbable. In this connection it must be mentioned that the virus has actually been recovered from bedbugs that have fed on the experiment- ally inoculated monkeys. . Another type of blood-sucking insects which remain quite closely asso- ciated with their host are various species of fleas. These insects, like the bedbug, never develop wings and consequently do not migrate extensively through their own activities. They can live away from the body of their host for a shorter length of time than the bedbug, but so far as is known, the time during which they can remain alive depends to a great extent upon the amount of moisture present in the air or in such loose dirt, rubbish, etc., as may afford them a hiding place. They undergo their developmental stages (egg, larva and pupa) either in the nests of rodents, cats, or dogs in the case of our common household species, or in accumulations of dust and fine dirt which may accumulate in the corners or cracks of floors in dwellings. Those species which occur on the cat, dog or on rats and mice are capable of considerable migration, since they usually remain on the host animal continuously after they have reached the adult stage, and thus go with it wherever it may wander. Until recently it was not believed by us that fleas agreed on any essen- tials of prevalence or possibilities of migration with what would be required of a carrier of poliomyelitis. Like many insects they were long ago sug- gested as possible vectors. Conn once regarded them as perhaps associated with the spread of poliomyelitis, but before enough was known epidemio- logically to examine them critically. Since Richardson advanced this idea that the disease showed an apparent relation to rats in Massachusetts the 157 flea question has received more attention. As the seasonal prevalence of fleas seems incompatible with that of poliomyelitis, it was suggested that data be secured on the relative abundance of fleas on cats during different parts of the year. From an examination of cats collected by the Boston Animal Rescue League during 1913-1914 it was ascertained that the sea- sonal abundance of fleas on cats corresponds quite closely to that of polio- myelitis, in fact more closely than that of the stable-fly at least during the winter. During the winter, fleas become scarce, especially in late winter and spring, attaining their minimum in this case during March, after which they rapidly increased until July at which time the observations had to be dis- continued. The persistence of fleas in smaller numbers during the winter is quite in harmony with the frequent continuance of poliomyelitis into late fall, and their rapidly increasing abundance during midsummer also coincides with the rise of the disease. If we now compare poliomyelitis with a disease known to be spread almost exclusively by fleas and rats we find a number of striking similari- ties, but also some very evident differences. A somewhat hasty examination of the literature relating to the epidemiology of bubonic plague made by Dr. Freeman and the writer, tended strongly to confirm our belief that there are many similarities between these two diseases in the development of epi- demic foci and the relation of the latter to scattered and more or less iso- lated cases. During recent times there have been no very extensive out- breaks of bubonic plague in temperate regions where the climate corresponds at all closely to that of the northern countries in which poliomyelitis has been closely studied. The progressive development of a number of small epidemics of plague that have been very carefully followed show a close simlarity to epidemics of poliomyelitis in their main features of distribution. This is especially true of the first general scattering of cases, the beginning of small foci and the way in which an epidemic spreads into new territory while the original small foci may gradually enlarge. As has been shown on previous pages, many features of the distribution and spread of poliomyelitis during the present epidemic lend themselves readily to interpretation on the basis of rats. These, as enumerated and considered in detail are, the grouping of the denser foci along the various water fronts of the city, their development in many localities without definite relation to the distribution and density of the human population, the spread of the epidemic in such a way as rats might be expected to migrate, the grouping of cases in neigh- borhoods and in houses, etc. The way in which the small groups of cases have appeared in certain city blocks and the marked tendency of additional cases in the same house to appear outside of the family or apartment are also more easily explained on this basis than upon that of personal contact. The greater incidence of poliomyelitis on the lower floors of the tenements and apartments is also plausibly explained in the same way. 158 The attempt has been made to ascertain whether rats or evidence of their presence could be found generally in houses where cases of polio- myelitis have occurred. In a great number of instances their presence has been satisfactorily shown by direct evidence such as runways or rat-holes. In others the information has been obtained by questioning residents of the buildings. The last mentioned is very unsatisfactory; in some cases there has been evident exaggeration, and in many others an equally evident desire to deny the presence of anything not considered proper, or anything tor which repressive measures might be required by the Department of Health. In others the proximity of stables, bake-shops, meat and poultry stores, etc., has given strong presumptive evidence of rats in at least small numbers. Not many trapping experiments have been tried, but where attempts have been made to obtain them from apparently suitable houses where polio- myelitis has occurred, they have been successful. These rats as was to have been expected have been found to harbor fleas. The great ease and rapidity with which rats may migrate in both city, suburbs and country have been shown by the spread of bubonic plague, and under urban conditions at least, by actual observations on market rats. Just what opportunities for migration and to what extent rats might avail them- selves of these opportunities in a city like New York is a question rather difficult of definite answer without considerable investigation. The occur- rence of rats on shipboard is notorious and there is plenty of opportunity for these animals to travel along the water-front following the movements of boats. No experiments have been actually carried on in the city, but there can be no reason to doubt that such travel actually occurs. As men- tioned on a previous page one small focus in lower Manhattan is closely associated with a second focus adjacent to another landing of a certain line of steamers. The apparent spread of poliomyelitis has often been seen to follow along water routes, an occurrence usually attributed to the move- ments of human freight. However, the fact that some of the most noticeable early foci in New York State this summer were about towns regularly visited by steamers from New York City is at least worthy of mention. More people travel by rail from New York City than by water and they reach their destinations more quickly. Nevertheless the water route has been the most rapid for the disease in this case, and the same association with ports has been noted before on occasions not within the scope of this report. Another method of travel open to rats is transportation in freight cars, either free or inadvertently imprisoned in packing cases. Plague follows the same course, and has in some cases been found to follow railroad routes. In cities the larger sewers support a considerable rat fauna, depending upon the construction, size and condition of repair of the sewers. The older portions of the city are supplied to a great extent with systems of bricked- in sewers which commonly harbor rats, while many pipe sewers, particu- larly in the newer districts, offer but small opportunities for rats to escape. Another way in which they may gain access to houses is through large 159 basement drains which open directly into the sewers without any water- trap. Whether certain streets which have been immune during the epidemic (e.g., E. 116th Street) are supplied with sewers different from those on the adjoining streets, has not been ascertained. It thus appears that rats and fleas show a number of striking peculiari- ties in distribution and behavior which are very suspicious when compared with the observed epidemiology of poliomyelitis. From the standpoint of experimental evidence there is no positive sup- port for the contention that the two are associated. No published reference to paralyzed rats has been made, but we have every reason to suppose that these animals are subject to paralytic diseases such as are known commonly to occur in various frequently observed domesticated animals like cats, dogs, horses, cattle, etc. In none of these animals, however, has it been possible to show that such paralyses as have been observed are identical with poliomyelitis. If we knew that no animal was susceptible, and that none could act as a reservoir for the virus the situation would be much clearer. To deny that animal reservoirs exist is taking much for granted, particularly as it is very probable that even in children a large number of abortive non- paralytic cases occur. That such cases should be the prevalent type in sone animal acting as a reservoir is at least perfectly plausible, and we should not expect to find the virus readily recoverable in large quantities from the unaffected spinal cord of non-paralytic animals. Since the spinal cord is the portion of the body usually taken for test, animal reservoirs might easily escape attention unless searched for with great care. Before leaving the discussion of fleas it should be noted that these in- sects were not eliminated in the experiments referred to elsewhere, where poliomyelitis was apparently transmitted successfully from monkey to mon- key by the bites of the stable-fly. The second type of insects suited to act as vectors for pathogenic micro- organisms are various actively flying species of blood-sucking habits. The most prevalent forms are mosquitoes and a number of allied flies belonging to several families, gad-flies belonging to the family Tabanidae, and the stable-fly and a few allies belonging to the family Muscidae. No others have a sufficiently wide distribution and occur regularly in all of the regions and localities where poliomyelitis has become epidemic. The status of the stable-fly has been already mentioned and has been dealt with in detail in other publications. It may be pointed out that the epidemiological evidence which so strongly incriminated this insect in studies of epidemics in smaller cities and in towns and villages does not apply with the same force under conditions existing in New York City. Like other flying insects, its behavior and comparative abundance is not compatible with the observed distribution and spread of the disease as enumerated else- where. Viewed in the light of the present epidemic, it seems equally easy to explain at least most of the previous epidemics on the basis of ratand, , ~N FIT AR pA 7 OF THZ UNIVERSITY Ne OF =~ XA 7 « \ » A ; 160 flea infection, and much easier to understand the development of this sum- mer’s outbreak in New York City on the same basis. Mosquitoes and their relatives do not seem to offer any promising lines of investigation. So far as our present knowledge goes there is no reason to believe that any of them could account for the conditions existing during the New York epidemic. They vary greatly in prevalence in different parts of the city, and while their relative abundance agrees more or less with the general trend of the epidemic, it is difficult to understand the definite foci which have developed, and gradually enlarged with so little change in shape and position. Like other flying insects, the movement of mosquitoes in the country is considerably like that of poliomyelitis, but not so in the city. This statement would not apply to a truly domestic species, like the yellow-fever mosquito (Aédes), but this species and the Filaria mosquito (Culex- fasciatus) are notable exceptions. The common rain-barrel mosquito (Culex- pipiens) is the nearest approach to this habit among our northern species. It is not generally prevalent in a city like New York. Certain conditions existing in some localities where Tabanid flies of the genera Tabanus and Chrysops are abundant has made it seem possible that these insects might act as carriers of poliomyelitis. The larger species are most abundant along the ocean beaches where these adjoin salt-marsh areas, along rivers, streams and ponds, or about stables, dairies, etc., where large animals are housed. The smaller species (Chrysops) occur almost ex- clusively in wooded areas and bite man commonly about the head and ears in all of our country districts. Like the stable-fly these flies feed normally upon the blood of animals of various kinds, but with the exception of the largest species, commonly bite human beings also. An extremely annoying species is abundant on the beaches where it goes by the name of “ green- head ” on account of its large brilliant green eyes. It is a very persistent and vicious biter. These flies have previously not been free from suspicion as possible carriers of poliomyelitis because of their general prevalence in the country and their abundance on the beaches which are visited so regu- larly by enormous numbers of persons with children. It is very easy to find that children have recently visited a beach resort and to be led to think that the visit is related to infection with poliomyelitis. The numerous small foci described on an earlier page preclude the possibility that poliomyelitis is usually contracted so far away from home as at the beach, and the lack of outbreaks of greater size in the summer beach camps, is additional evi- dence. However, these flies frequently occur about stables, even in the centre of the city, where they have evidently flown for considerable distance, since the species breed in marshy lands about streams, ponds, etc. They are attracted only to living animals, however, and do not occur about markets or food shops. Since their bite is severe, it is usually remembered, but only one definite history of a bite of this kind can be recalled after visiting many families where poliomyelitis has occurred in the several boroughs. This does not include beaches; there they are by no means uncommon. 7 161 The house-fly has been very frequently mentioned as a possible carrier of the poliomyelitis virus. Its activities have been supposed to be accessory to contact infection from person to person through the medium of the nasal secretions. The flies could of course also secure the virus from fecal dis- charges or from the secretions or excreta of animals if it exists in such places. In any case they could act only as accessory to some other method of infection. occurring, for example, through the nose or mouth, since flies are attracted to the mouths and noses of very small children as well as to an unprotected wound or surface lesion of any kind. Food might of course become infected in the same way. House-flies may thus be called upon to explain a large percentage of cases where direct contact or carrier infection cannot be shown to have occurred. It is very difficult to analyze a combination of possibilities of this sort, as one sees by recoliecting the widely variant views which have been held till recently concerning the relative importance of the house-fly in disseminating the typhoid bacillus. With poliomyelitis the situation is much more difficult on account of lack of knowledge, of many of the im- portant factors concerned. It appears, however, that the numerous dif- ferences in the abundance of house-flies in certain sections of the city ought to be definitely reflected in the incidence of poliomyelitis if this insect be a factor. This is not the case, so far as has been ascertained. There are a number of streets very heavily supplied with flies, attracted to pushcarts full of vegetables and other sorts of food, in certain parts of the lower east side. Adjacent to these streets are others where there is no special attrac- tion for flies. There has been no excess of poliomyelitis on such “fly- streets.” Flies cannot readily account for the restriction of the disease to blocks either, since flies should show at least as great a tendency to cross the street as to travel along a block or to cross through it into the buildings on the near side of the next street. It is also difficult to see why they should not cause the larger foci, which involve areas including a number of adjacent blocks, to spread more diffusely into the currounding territory than has actually been seen to be the case. At any rate we should have to regard the house-fly as only a contributing factor, additional to spread by contact. That it should act as it does in typhoid-fever by contaminating food is an assumption not supported by any evidence. The failure of certain outbreaks to disappear with the house-fly in the cool months speaks against it as a factory also. The persistence of the present epidemic in Massachusetts is a case in point. The only other Arthropods suited to convey infections of warm-blooded animals are the ticks and their allies. So far these insect-like animals have been shown to carry only Spirochetae-Piroplasmata and similar organisms. They can be absolutely eliminated as far as human infection of poliomyelitis is concerned. : The development of epidemic foci of large size in. various parts of the eastern United States apparently as the direct result of introduction of the 162 infection from New York City this summer, throws new light upon the peculiar restriction of poliomyelitis to the summer months. This also supplements and confirms observations on the course of the New York City epidemic in the various boroughs. It is evident that the course of the epidemic has been at first gradual and later has shown an increased rate of acceleration till the maximum daily incidence is reached ; after this the decline has followed an inverse direc- tion. In New York City this rate of acceleration has been greatest in the Borough of Richmond, producing a higher incidence in this borough till late in the season when its incidence was exceeded by that of the Borough of Queens. This rate seems to be much more rapid in the more rural por- tions of the city, even in the more sparsely settled portions of the Bronx. It is also very evident that the early start of the Brooklyn epidemic is casually related to its earlier decline, while the subsequent appearance of the epidemic in Manhattan and Bronx is resulting in a later decline in these boroughs, in the same order as that in which they were attacked. This makes it appear almost unquestionable that there is a very definite period required for an epidemic to develop and subside and that this period has been almost identical in length this summer for the several boroughs. When this is taken in connection with the late development of the epidemic in Massachusetts and its later persistence in that state in spite of cooler weather than prevails in New York, it is seen that summer epidemics are not regulated by temperature nor by insect prevalence alone. It seems equally evident that one or more factors necessary to produce an epidemic are not present in the winter except in very rare instances. However, once an epidemic has started, it appears to run its definite predetermined course even though this may be prolonged much later in the season in New Eng- land than in southern New York. From these facts it would seem that any insect responsible for the spread of poliomyelitis, must be one which remains prevalent much longer in the autumn than the time at which epi- demics usually disappear. The stable-fly and fleas of various sorts would fit this requirement, The majority of other insects do not appear to do so satisfactorily on account of their more rapid disappearance upon the ap- proach of autumn in our climate. : CONCLUSIONS. Some new facts of interest and importance relating to the possible transmission of poliomyelitis by insects have resulted from the present study, but these are not so definite or complete as had been hoped. They are also to some extent of apparently conflicting nature, and require at least one unproven assumption to combine them into any working hypothesis. They do not completely disprove the idea that the stable-fly (Stomoxys cal- citrans) is implicated, although the behavior of the present epidemic does not favor this view. To discard it is to cast aside evidence derived from TIT yr 163 two sets of experiments, however, and it seems very unwise to do this at the present time of uncertainty. As has been shown, it is possible with one assumption to form a working hypothesis based upon rats and fleas which seem to fit the epidemiological observations in general features and in many details as well. The assumption that the rat can act as a reservoir for the virus of poliomyelitis should be capable of experimental proof, and it would seem that such experiments should be attempted. This by no means precludes the association of some other insect or warm-blooded animal, or both. In fact, there is a continual appearance of circumstantial evidence that suggests a population other than the human one, acting as an undercurrent and influencing the progress of the epidemic. When the many factors so far in doubt are gradually made known, it will be possible to attack the entomological side of the question with better promise of success. Among the unknown factors which cause the greatest confusion in interpreting epidemiological evidence are (1) the length of the period of incubation (2) the number of mild, abortive or unrecognizable cases and carriers of the virus and their relation to infection and immunity ; (3) the duration of infectivity in clinically recognized cases: and (4) posi- tive knowledge of the presence of the infective agent in insects, domestic animals, or other possible intermediate hosts or reservoirs of the virus. THIRD AVE. BOWERY pe 52 acres 47 acres 43 acres Pop. 30,400 Dp. 2n Pop. 18,800 16 cases 0.8 per 1,000 21 cases 56 acres 0.5 per 1,000 y 1.1 per 1,000 Pop. 28,600 54 acres 18 cases Pop. 37,700 0.6 per 1,000 ch 0.8 per 1, 51 acres 52 acres 43 acres PD. 44000 Pop. 25,500 Pop. 25,700 0.6 per 1000 15 cases 43 cases : 0.6 per 1,000 1.7 per 1,000 40 acres Pop. 25,100 19 cases 0.7 per 1, 46 acres 52 acres 43 acres Pep sn Pop. 42,000 Pop. 23,500 cases cases 4, ip 0.6 per 1,000 0.7 per 1,000 1.3 per 1,000 op. ) 19 cases 0.7 per 1,000 1.0 per 1.000 Population 539,300; 545 cases; incidence 1.01 per 1,000. Mar 1.—Part of the lower east side of Manhattan, showing the area, population and several sections. 55 acres a acres Pop. 27,100 op. 5,600 Po 219.900 42 cases po 39 acres 1.5 per 1,000 1,000 Pop. 16,300 dl 16 cases 16 cases 1.0 per 1.000 FOURTEENTH ST. incidence of poliomyelitis in the WATER FRONT sas. ~~ n &K | 47 acres 50 acres 47 acres = | Pop. 3,900 Pop. 6,300 Pop. 3,500 = | 8cases 25 cases 3 cases 2.0 per 1,000 || 3.6 per 1,000 || 0.8 per 1.000 Amsterdam Ave. Population 20,800; 42 cases; incidence 2.0 per 1,000. Map 2.—Area on the upper west side of Manhattan where there was an extensive outbreak of poliomyelitis. . W. 28 wi s 00 © |<[e0000 & wi << é = = = Ze x z|0 000000 sve 5 W. 26 B C D CHELSEA PARK W. 32 W. 19 W. 27 &@ j $0 ol ® ; 4 ul La ze £ =z © 0 eo |: si eo ® 00 |= E W. 31 = = W. 18 =m W. 26 = = ~ be = = z= Er e%s EE EE # i 4 © @ - ® oe W. 30 W.17 W. 25 a BN oe © Fic. 1.—Four groups of cases of poliomyelitis on the west side of Manhattan, illustrating the typical grouping of cases. Each dot represents one case; those along the street show the approximate position of the house and those away from the street, additional cases in the same house. Basement 1st. floor 2nd. floor 3rd. floor 4th. floor 5th. floor 6th. floor 7th. floor Top floor g 8 23.9 320 300 280 240 220 180 10.0 80 —— 4 P-10 | P-03 60 ----98 : D-1.7 | D-08 2s -3.9- 20 - Poliomyelitis 1586 cases —=-—-—-= Diphtheria 796 cases ===-===-- Scarlet fever 652 cases Fic. 2—Chart showing the prevalence of poliomyelitis, diphtheria and scarlet fever on the various floors of dwellings in Manhattan. The number of cases is shown by the figures at the left of the chart, and the percentage of cases upon a given floor is shown by the figures placed in the vertical columns. 240 220 180 160 140 120 100 80 20 Basement 1st. floor 2nd. floor 3rd. floor 4th. floor 5th. floor 6th. floor 7th. floor Top floor sn io sae = _ E— "3 -—— en en = em =H Poliomyelitis ¢==smm. =.=: Diphtheria ========== Scarlet fever Fi6. 3.—Chart showing the prevalence of poliomyelitis, diphtheria and scarlet fever on the various floors of dwellings in Manhattan. lines representing each disease are reduced to the same scale, the numbers at the left representing tenths of one per cent. The Basement Ground 1st. 2nd. 3rd. 4th. Top Misc. 275 250 225 175 150 125 100 7% Fi6. 4.—Distribution of 857 cases of poliomyelitis on the various floors of dwellings in Brooklyn. Figures at the left indicate number of cases. ST Potiomyenus mmaemm nem ans =. Soarict fever Frc. 5.—Chart illustrating the relation of additional cases of poliomyelitis and scarlet fever to first cases in the same house. Thick lines indicate additional cases in the same family and thin lines denote additional cases in the same house but in a different family. The actual number of cases is indicated by the figures at the left of the chart. The figures at the top of the chart show the number of days elapsing between the onset of the first case and the onset of the additional one. Thus 62 additional cases had their date of onset coincident with that of the first case, 42 were one day later, 33 two days later, etc. = I eres jet i = Ss CHAPTER VI Poliomyelitis in New York State in 1916. SUMMARY OF EPIDEMIOLOGICAL DATA. The following data are abstracted by permission from the Preliminary Report of the State Department of Health on Poliomyelitis in New York State in 1916: Poliomyelitis was made a reportable disease in this State in 1910, but no extensive outbreak occurred until 1912, namely, that which began in Buffalo and spread eastward. This outbreak started in June, reached its height in August, and ceased in October, resulting in a total number of 306 cases. In Batavia, about thirty-five miles to the east of Buffalo, the outbreak began in August and stopped in October; a total number of 26 cases was reported. Since 1912 many cases of poliomyelitis have been reported from various parts of the State, chiefly from the western portion, 609% being re- ported in the western third of the State, representing 36.6% of the popula- tion outside New York City. Total Number of Cases and Deaths of Poliomyelitis in New York State Since 1910. Exclusive of New York City. Year. » Cases. Deaths. Cases. Deaths. 1080. aii Os Eva t rs we SRT 112 58 112 AOL) ove veers hin hiris 2 139 52 139 1812, rina 35 dnt Eris si ein 1,108 183 604 a Lee Cl 491 123 181 66 13 a I IY Ne 224 68 96 29 p17 3 I nd 257 50 162 34 1016.55. ovine iis snare tie wid *12,574 3,331 **3 565 81 * Corrected figures (Jan. 15, 1917), 13,164 total cases. a ; **Corrected figures (Jan. 15, 1917), 4.155 total cases (excluding New York City). Cases appeared in various parts of the State during 1916. The epi- demic was not recognized until the latter part of June, when the outbreak occurred in New York City. The disease spread rapidly to the counties surrounding the city, Nassau and Westchester, and then followed the lines of travel up the Hudson River, along the Mohawk Valley westward to Syra- cuse, then it extended northward into the western counties of the State. The largest weekly number of cases reported in Nassau County occurred during the week of August 13th to 19th; in Onondaga County, two weeks later; and in St. Lawrence County during September 10th to 16th. 8 180 The table given below indicates the incidence of the disease by weeks and months for the months of June, July, August, September and October: June. July. August. September. October. ree, S } A a Nr TE She . Weeks. Cases. Weeks. Cases. Weeks. Cases. Weeks. Cases. Weeks. Cases. 1-6 3 4-10 71 7-13 421 4-10 336 3-8 143 7-13 2 11-16 R6 14-20 482 11-17 259 9-15 92 14-20 3 17-23 182 21-27 428 18-24 244 16-22 62 21-27 15 24-30 229 28-3 378 25-1 169 23-29 33 28-3 31 31-6 351 he ae cae ow 30-4 er N.Y. State i ad go 54 929 1,709 1,008 355 City 335 4373 238; 878 315 This table shows that the disease, commencing in June, gradually in- creased during July and reached its maximum incidence in August, about the middle of the month, having attained its height a little earlier in the City of New York, and that after that time it steadily declined, until by the end of October there were comparatively few cases reported. The total number of cases reported in the State, up to January lst, 1917, was 13,164, of which 4,165 occurred outside New York City. The following curve indicates the general incidence of the disease by weeks during June, July, August, September and October. The map shows where the cases were located. . INCIDENCES OF [P0LIOAY £41775 +N NEW Yor Sragre [5/6 /Foo /\ /Roo / \ oo A) yo000 ~ Ht Cases Heporded 1m Nem York Cy —4— |Coses ST 7 (out: foo of MY CF 8oo my \ | Soo C rs £ (Ss > / 7 ’ / A Hoo [7 / " / / \ Joo L \ NG Zoo / = 2 ~ eg 7 O / N Zz N Joo == Lo rz het” _|_ = . ol op /-6 |7-73 /g-20(2/-27128-3 |g -10 |/1-16|r7-23{24-303/-G (7/3 /4-202/-27\28-F|R-10 11-17 8-24 25-1 R-& |7-/5(/6-21|23-2930-¢ Tec e July Augeas? Sablember OcZober Wee ks of Summer 77/6. 18472 Shin DISTRIBUTION OF CASES OF POLIOMYELITIS IN NEW YORK STATE, OUTSIDE OF THE CITY OF NEW YORK, ON SEPTEMBER 30, 1916 185 An exact idea of the case fatality of the disease cannot be given on account of the large number of non-paralytic or abortive cases which were unrecognized and not reported. From June lst to November 1st, there were reported, outside New York City, 3,554 cases with 844 deaths, making a fatality rate of 23.7%. In New York City, during the. same period, there were 8,928 cases reported with 2,407 deaths, making a fatality rate of 26.96%. In the State there were, therefore, reported 12,482 cases, of which 3,251 died, or 26 plus per cent.* As soon as it was realized that an outbreak of poliomyelitis was immi- nent, the State Department of Health instituted an active sanitary cam- paign, and provided the necessary organization and equipment to carry out adequate measures to prevent the spread of the disease. A special investigation was made of the epidemiology of poliomyelitis, the results of which accord very much with those obtained by the Depart- ment of Health, New York City. Regarding the prevention of the disease, the conclusion was reached “that it will not be possible to establish ade- quate and precise measures for the control of this disease until, first, the limits of the reservoirs of infection in nature are definitely known; and second, until the exact means of transmission has been worked out.” In an exhaustive study of 1,081 cases of poliomyelitis, these points are emphasized: 1. 577 were males and 504 were females. 2. The age incidence having the largest number of cases was 2 years; 499, were under 5 years of age. 44 cases were under 1 year. 106 cases were over 1 year old, but under 2. 188 cases were over 2 years old, but under 3. 126 cases were over J years old, but under 4. 121 cases were over 4 years old, but under 5. 87 cases were over 5 years old, but under 6. 84 cases were over 6 years old, but under 7. 37 cases were over 7 years old, but under 8. 45 cases were over 8 years old, but under 9. 47 cases were over 9 years old, but under 10. 16 cases were over 10 years old, but under 11. 21 cases were between 11-15 years old. 44 cases were between 16-20 years old. 38 cases were between 21-25 years old. 19 cases were between 26-30 years old. 3 cases were between 31-35 years old. 3 cases were between 36-40 years old. 1 case was between 41-45 years old. 2 cases were over 50 years old. * These figures to be corrected later when additional data have been collected through the poliomyelitis clinics held periodically throughout the State. 186 3. Associated in the families with poliomyelitis with those 1,081 cases were 2,579 children, and 3,511 adults, making a total of 6,090 exposed per- sons. Of the 1,081 cases only 24 were associated with other cases in the same family. 4. In 131 instances the patient was a visitor from out of town. 5. Information about the financial status of the family was obtained in 445 instances. Of these, 140 were in families of the poor, 260 families were in moderate circumstances, and 45 families of the well-to-do. 6. There seems to have been no relation between sanitary conditions and the incidence of cases. Sanitary conditions were bad at the homes of 156 cases, fair in 302, good in 340, and excellent in 215 cases. 7. The previous health of the patient had been poor in 68 cases, fair in 18 cases, good in 372 cases, and excellent in 512 cases. 8. Paralysis appeared before the 4th day of the disease in 719 of 700 cases as follows: 189 had paralysis on the 1st day of illness. 203 had paralysis on the 2nd day of illness. 142 had paralysis on the 3rd day of illness. 85 had paralysis on the 4th day of illness. 48 had paralysis on the 5th day of illness. 29 had paralysis on the 6th day of illness. 20 had paralysis on the 7th day of illness. 14 had paralysis on the 8th day of illness. 6 had paralysis on the 9th day of illness. 3 had paralysis on the 10th day of illness. 2 had paralysis on the 11th day of illness. 2 had paralysis on the 12th day of illness. 1 had paralysis on the 13th day of illness. 4 had paralysis on the 14th day of illness. 1 each on the 15th, 16th, 20th and 21st days. 9. The nationality of the parents was largely American. 709 fathers and 700 mothers were born in the United States; 70 fathers and 61 mothers were Italians. 10. Animals on the premises: There were horses present on 141 premises, cows on 151 premises, sheep on 1, dogs on 162, cats on 189, pigs on 79, goats on 5, and fowls on 284. The following general observations on the outbreak as a whole are of interest: I.—“ The onset of the epidemic was in New York City, which gradually spread up-state. The most heavily infected region was on the southeast corner of the State. The height of the epidemic ap- peared in Nassau and Westchester Counties in August, while in the upper counties of the State it appeared in September.” 187 IT.—* The cases seemed to follow the course of railroads, indi- cating that travel may have had something to do with the spread of the disease.” III.—* No milk-borne outbreaks of poliomyelitis were reported. (Neither were there any milk-borne outbreaks of scarlet fever and typhoid during the same period.) The same safeguards were used on dairy farms where cases of poliomyelitis existed that were em- ployed when typhoid fever or scarlet fever occurred. Poliomyelitis was reported on 112 farms during the summer.” IV.—“ No water-borne outbreaks of poliomyelitis were noted.” V.—"“The seasonal prevalence corresponds to that of typhoid fever. The largest number of cases were reported in August. In previous years the largest number of cases had been reported in September.” VI.—“1t is difficult to estimate the exact value of the quarantine measures adopted. In many instances quarantine measures have been enforced vigorously and in other places with laxity. But because adults were not restricted it is evident that only a partial quarantine was maintained. It is significant that institutions located in the midst of infected districts where complete quarantine was rigidly main- tained have been free from infection.” The factors demanding special attention are pointed out to be: a simple method of detecting the infectious agent, or at least, of detecting where it is located; a careful study of small groups of cases in order to determine what part of the material transferred from the nose and throat and alvine discharges, from one person to another, has to do with the incidence of the disease; a careful study as to what constitutes immunity from this disease —who are immune and why; an entomological survey of the homes occu- pied by small groups of cases to determine the common insect life in these homes. CHAPTER VIL Pathology. The morbid anatomy of acute poliomyelitis has received careful and painstaking study by a number of European pathologists, chief among whom are Wickman, with a study of fourteen cases, Harbitz and Scheel* with nineteen cases, and Strausj with eight cases. The findings by all of these workers happily coincide, so that this phase at least of the poliomye- litis study may be said to be practically settled and free from conjecture. Because of the importance of functional diagnosis and the primary in- terest in connecting the physical signs and clinical findings with the morbid anatomical lesions as disclosed at autopsy, the emphasis in the reports has usually been put upon the character and location of the lesions in the central nervous system. This has led to a false conception of the true nature of the disease which from the general distribution of the lesions among the lymphatic and glandular tissues of the body, as well as in the brain and spinal cord, should be that of a general infection with the commonest focal symptoms resulting from the damage to the anterior horns in the cord. Many of the general symptoms and not a few of the clinical signs of value particularly in the early preparalytic stage of the disease, result from the general invasion of the body and particularly the lymphatic tissues. It is important to the further study and early recognition of non- paralytic cases that the general, rather than the purely central nervous system lesions of the disease be accepted as essential and typical. In the present epidemic, post-mortem examinations were performed by pathologists of the Research Laboratory of the Department on forty cases of poliomyelitis, thirty-eight of which died in the acute stages; thirty-six were cases from the Willard Parker Hospital, and four were done in private residences. Nine other cases came to autopsy from the poliomyelitis hospital wards, four of these proved to be tuberculous meningitis; one broncho pneumonia ; one congenital heart disease; one purulent pericarditis with purulent pleuritis, broncho pneumonia, and general pyemia; and one intracranial hemorrhage. The poliomyelitis cases confirmed at autopsy, are divided as to sex, age, and duration of illness: Sex—Male, 37; Female, 13. . Age pio Liyear civ viii saan msvaent as 8 NCTE EL Cb NE eR LI SI SR 8 20 FJ YEATES vai es ania ae ay A ae a eas 13 * Harbitz and Scheel: Pathologisch-anatomische Untersuchungen ueber akute Poliomyelitis, Vidensk Selsk. Skr., Christiania. 1907. + Straus: Report of Collective Investigation Committee in the N. V. Epidemic of Poliomyelitis, 1907—Jour. of Nerv. & Ment. Dis., Monograph Series, 206, 1910. 189 Age. 3-105 YEA visi cai deat ss sae Isles Bein aa Sia 2 S510 10 YEAS vhs teas van rmrs bers Eres naa visa 3 1010 10 years . «=. viii See foneh avin deh adv sish 1 Ver 16 YEONS + va 1 12 sp iinems Shanes Saiismate dais His oidi 5 Up to and including 5 years there was a total of 31 or 77.5%. Duration of Illness— BABYS (ovieesnintins singin tnt Awe isn tte are bl 10 4 A0Y8 io iinir iiss s sural tne navy 5 BS days ..ovaerrsinnrrmennsssngsehalann sen anilion 6 6 days ir sy sie des we se AE a Els ete 3 RNP LN A RAIN Ar rin fT 5 S40 11 days iu puis vicahon di sam nina lninis mens dons 3 OVEri 12 -Aa%8 sire ininr enim si shan Bam ses slpahin 4 Undetermined number of days .................... 2 31 or 77.5% of the cases died within the first week after onset. The clinical classification as to type is based on the evidence of anatom- ical lesions. Thus, all cases exhibiting involvement of the lower motor neurone were called spinal cases. These were again divided into two classes; one in which the process begins in the lumbo-sacral cord and progresses upward involving the arm and respiratory centres, and the other in which the process begins in the cervical bulbar regions or in the gray matter from which the cranial nerves have their origin. Those cases exhibiting disturbance of the upper motor neurone or other disturbances of the sensorium belong to the cortical type. Those cases showing only marked meningeal symptoms were considered to be of the meningitic variety. They are as follows: Types of Cases. Ascending spinal ouch. Gualivaiia lie defies alsa. 16 Upper spinal wo. cave vislud hai wins frre stashins mvp 18 EO Ee Sr Ee eae 3 Meningltic Jo iiwe ei dinhls sas i slal bait are bina owns 3 One of the ascending spinal cases survived the poliomyelitis infection and died of lobar pneumonia thirty-four days after the onset of illness. Another case belonging to the upper spinal group died of acute gastro- enteritis twenty-eight days after the onset of the polio-infection. The gross changes when in the brain were usually those of varying grades of congestion of the pial and parenchymatous vessels; of edema of the pia and brain substances. In a few instances the brain tissue was of softer consistency than normal. One brain, in a man of twenty-seven 190 years, besides intense congestion of the edema, presented extreme softening in one hemisphere involving the motor area and a great portion of the parietal lobe, in which lies the sensory area. Clinically, this man presented a hemiplegia and hemianesthesia of the opposite side. The brain tissue was reduced to a mushy consistency with multiple hemorrhagic flecks throughout the cut surface. No gross hemorrhage was visible and the spinal fluid was clear, with changes such as one would find in poliomyelitis. The Wassermann reaction was negative. This is the only cortical case simulating apoplexy that came under observation, at the Willard Parker Hospital, among a great number of cases. The changes in the spinal cord were observed commonly on cut sections through the pons, medulla and upper cervical portion, it being our intention to preserve as much material as possible, in a clean state, for cultures, microscopic study and animal experi- mentation. The cut sections presented degrees of hyperemia and swelling of the gray matter. The gray matter bulges above the level of the sur- rounding white matter and is sharply demarcated from it. In marked cases, the gray matter would be very red, and in some there were what appeared to be small punctate hemorrhages. In other cases, the gray matter is simply pink-tinged and easily marked off from the surrounding white matter. Sections through normal cords fail to show the ready differentia- tion between gray and white matter which is to be observed in cords from poliomyelitis infection. In some cases the edema involved the white matter as well, and appeared to soften the cord as a whole. The heart and lungs showed no striking changes except that practically all of the lungs presented acute edema and congestion incident to the paralysis of respiration. The liver and kidneys showed varying degrees of acute congestion and, in some cases, parenchymatous degeneration. Particular attention was paid to the lymphatic structures as some observers contend that lymphoid tissue plays a considerable role in the pathologic picture of acute poliomyelitis. The lymphoid structures of the small intestines, the Peyer's patches and solitary follicles, in a number of instances, exhibited proliferation and congestion. The mesenteric lymph- nodes were enlarged and reddened. The spleen, in many instances, showed marked congestion and varying degrees of hyperplasia of the malpighian bodies. Following is a tabulation of gross changes as above described : Not Noted Present. Absent. or Examined. Balls on ne i cE ER SA PA 35 5 2 Bord or ics nisms cbs BEE rar 3 tad Sr te 20 5 15% IEE RAR ths a nian Bh saan ra a 16 8 16 Meserteric INOAER « siuhiics tueehsissins vr sured themes 19 10 11 Sn A SC EN I 18 16 6 * Showed no changes at the level of the sections made. 191 A number of the autopsies were granted only for the examination of the brain and cord, and this fact accounts for the incompleteness of the data as to the other organs. The microscopic pictures of our cases are now in process of study. Such as have been looked over correspond with those so carefully described by Wickman, Harbitz and Scheel, et al. The changes in the affected portions consist chiefly in a perivascular round cell infiltration, engorgement of the blood vessels, edema of the interstitial tissue and destruction of nerve cells. The pia mater is affected most commonly in the sacral and lumbar regions, though congestion of the vessels and infiltration of cells about them may be found in any section of the cord. The gray matter of the anterior horns show, as a rule, the most marked changes, though, in some cases, the posterior horns, especially the gray matter of Clark’s column, may be densely infiltrated. Those sections which are the first to bear the brunt of the attack, as a rule, show the severest changes in the ascending spinal cases, usually the sacral and lumbar region; in the upper spinal type, the cervical region, the gray matter about the floor of the fourth ventricle and aqueduct of Sylvius. In the brain, the regions most seriously affected are the basal ganglia, though the cortex at all times shows changes, most marked, usually, in the motor areas. The intervertebral ganglia, in some cases, have shown changes similar to those seen in the gray matter of the cord and brain. The cell types, which go to make up the infiltrated mass, consist chiefly of polymorphonuclears, lymphoid and cells derived from the lymphoid cells called poly-blasts. These latter cells have a relatively larger amount of protoplasm than the lymphocytes and its nucleus is paler staining and fasiculated. This cell, as well as the polymorphonuclear cell, exhibit the function of neuronaphagia, that is, they break up and carry away nerve cells that have been destroyed by the virus of the disease. They can be seen in the process of invading the damaged nerve cells, fragmenting it and carrying off the debris. As to the source of these cells, different authors have different opinions. Some think they are derived from the white cells of the blood; others that they are produced by a proliferation of the fixed cells of the adventitia of blood cells; others that they are derived from the neuroglia of the central nervous system. While the cell infiltration is, as a rule, most marked about the blood vessels, forming a cellular collar about them, as it were, there are to be noted marked diffuse infiltrations as well. The nerve cells, in the neighbor- hood of most of these, indicated degenerative changes. The cell body swells, and becomes more globular. A disintegration if Nissl’s granules occurs. If the process extends, the nucleus is converted into a deeply staining irregular shaped structure. Sometimes complete destruction of nucleus takes place. After this happens, the neurophages enter and clear away the debris. 192 The edema, when marked, converts the neuroglia into pale staining granular mass. The bundles of nerve fibres, in the white matter, are separ- ated by the accumulation of fluids between them. It is this factor that has to be reckoned with in the explanation of the transient paralyses that occur in this disease. No large extravasations of blood are to be seen. Here and there, small accumulation of red cells have apparently broken through a thin capillary wall. These minute hemorrhages would not show up on gross inspection. So much for the stage of destruction. In the reparative stage, there is recession of cell infiltration, disappear- ance of the edema and congestion. The neurophages are carrying off the destroyed nerve cells. There is a proliferation of the neuroglia tissue which gradually replaces the destroyed nerve element. As this neuroglia ages, it contracts and so forms the scars which are to be seen on sections of the cord from old cases of poliomyelitis. As a result of the destruction of the nerve cells of the anterior horns, there is a secondary degeneration of the peripheral nerve fibre, and a consequent atrophy of the muscle sup- plied by that fibre. The upper motor neurone, which connects with the nerve cell in the anterior horn, also undergoes atrophy because of lack of function. The microscopic changes in the lymphatic structure consist, generally, of an acute congestion, with hyperplasia of round cells, such a picture as one may find in any generalized infection. The pathogenesis of poliomyelitis is still an open question among pathologists. Some think that the virus has a direct destructive effect upon the nerve cell, and that the vascularity, edema and round cell infiltration are only the evidence of the body reaction to the presence of the virus. Another school of workers considers nerve cell degeneration secondary to the marked inflammatory reaction; in other words, that the nerve cell is destroyed in a mechanical wav by the effect of pressure of the engorged vessels, edema and cellular infiltration. We agree with the opinion of that school of pathologists which con- siders the virus a specific nerve cell poison, in a manner analogous to the virus of rabies, tetanus and diphtheria toxin. If one concedes that the infection is principally manifested by disease of the central nervous system, and this is the consensus of opinion, then one must also concede that it is the active elements of the brain and cord, namely, the nerve cells, which have special affinity for the virus of poliomyelitis. It is probable, however, that edema and congestion play a considerable part in the production of the transient paralysis observed in this disease. With the recession of the edema and congestion, nerve cells, which have been rendered temporarily incapable of performing their functions, are restored to their normal state. Two factors in the pathogenesis of this disease, the specific cell poison and edema and congestion, are necessary to explain the commonly observed clinical manifestations of acute poliomyelitis. 193 As indicating the location of the lesion which, in the great majority of the cases, appears to determine the fatal issue, the following summary is included, giving the result of a study of 1,500 of the fatal cases, by imme- diate personal inquiry and verification of the clinical history and record as soon as the death certificate was received at the Department of Health. Death was attributed in 619% of the cases directly to respiratory failure. In 35% more cardiac failure appeared to share in, if not actually to dominate the picture as the cause of death, but in these cases also respiratory failure was a serious factor. In 49, death resulted from other causes superimposed upon poliomye- litis, as in specific instances, pneumonia, cerebral, hemorrhage, and gastro- enteritis. Among 1,390 of the 1,520 cases which were thus studied and in which the data were sufficiently complete to be trusted, there were 79 patients in whom the paralysis appeared to have been limited to the muscles of respira- tion, 456 in whom paralysis existed in other groups of muscles as well as in the respiratory group. There were 58 in whom the muscles of the pharynx and larynx alone appeared to be involved, and 354 more where these muscle groups, as well as muscles of the trunk and extremities were involved. Of these same 1,390 cases it is recorded that: In 258 there was paralysis of all four extremities. In 52 there was paralysis of three extremities. In 443 there was paralysis of two extremities. In 266 there was paralysis of one extremity. ~~ In the appendix will be found a table (XXII) summarizing the proto- cols of each autopsy. Parnovrocricar. ConpitioNs oF NOSE AND THROAT. In view of the fact that the nose and throat are believed to be the chief modes of entrance to the body of the virus of poliomyelitis, the question naturally arises—what proportion of these organs show actual pathological conditions? In order to answer this question definitely, a special study of 2,000 poliomyelitis patients in the Department Hospitals was made by one of our most expert laryngologists. The results of the investigation are tabulated below : Age Ratio : Percentage Age Ratio Age of Cases Examined. 0/2000 Total Cases. Epidemic. Upto livear. io. cone. inns 279 13% 109, Number of cases [Over 1 year up to 5 years of age, 1,392 729% 73% examined 2,000{Over 5 years. Under 16 years (ochool age) J. iis iis ns aie a i244 129, 129, (Over 16 years of age. .......... 40 29% 1.99, 194 Patho- Adenoids Cases Percentage logical only or Cases with Ratio Condition Retro- with Patho- Patho- Tonsils pharyngeal Number Normal logical logical and Obstruc- Ages. Examined. Conditions.Conditions. Cases. Adenoids. tion. Upto Lyear........ 279 177 102 36.5% 66 36 Over 1 year up to 5 years of age....... 1,392 499 893 64.19% 829 04 Over 5 years under 16 years of age....... 244 141 103 42.29, 98 3 Over 16 years of age. . 40 33 7 17.5% 7 0 Number of cases without previous operation, nose or throat..... 1,955 Number of cases completely recovered discharged from hospitals 550 out of 3,800 Percentage Ratio ae, ross srs ssidns xdnsiruiasing naassin doe saskasss 15% Number of cases having previous operation, nose or throat........ Number of cases completely recovered with previous operations. . 19 out of 39 Bercentage Ratio ont a. i sir vetins vasmemirunsimonnismn sss syerns 46% SUMMARY OF RESULTS. 1. A large number of children with poliomyelitis show pathological conditions of the nose and throat, either diseased and hypertrophied tonsils and adenoids or both. 2. A large number of children with poliomyelitis show marked hyper- emia of the naso-pharynx and throat (tonsils and anterior pillars and soft palate), often resembling a scarlet or streptococcus throat. 3. Only a small percentage of cases, previously operated for tonsils and adenoids, were found to be affected with the disease, and in that group of cases the percentage of recovery was very much higher than in unoperated cases. The number of cases in this group is, of course, rather small to draw from it any definite conclusions, but it is at least suggestive. In another investigation of 1404 children in the public schools, made to determine whether any children, whose tonsils had been removed, had been ill with poliomyelitis during the recent epidemic, a similar result was obtained. The investigation was conducted by trained nurses, under the direction: of an experienced District Medical Supervisor of the Department, and the children were examined in thirty public schools. Following is a list of the number of children operated on by ages, and of the date of operation: Numer oF CHILDREN OPERATED ON, BY AGES. SYEArs (Of age. A ie eres ireide Siriaas 7 6 Venrs OL HAE. Naiethii ney hon inine inl ecnininbiiins » 87 Ziivears ioDinge. tinh, fain Sol Tal ih aie sine + 191 Siyearsiof AC. Jr raids ae tn x 271 OQ yenrs Of Qe. dives ss ss ston tintin vnsasnnes 271 10 years Ol age. Jaci esa vivs tan Vann tein 220 ll years of age. conv corre vedi ni rate ves 194 12 years of age. ikon svi sr ivasaain nse e 157 13 years of (ame. i rainy csv reir a rani e 4 14 years of age... coins danas ds a napn nn ie 2 DATE oF OPERATIONS. i Cases‘opeiated IMAG... 0 sos widens ison . 299 (prior to epidemic) Cases operated in 1018... co fy cnminindr in Sov 464 3 : Cases operated dn 1914, .. co ve divnine vo ws vrais 323 Casesioperated dn 1913.50 55% 22 vans sa esis same 150 “* gees operated in 1012... . ii iiin ts pate 112 5 ses operated MV TOLL... ovo siincisisinainisnin s 5 a nina 33 Se Cases operated An IO. 5... Fis oidinin sn sven 13 5 Cases operated in 1909..............covvnveennss 4 pe Cases operated In 1908..............co0vuivsusnn 4 4 Cases operated in 1907............ RUE ae) 1.4% : Sr Cases operated in 1900... s Fs wr sivrnncuns sin 1 an POL 8 fries s sini eds sassaas wes « sade os 11,404 Of the 1404 children where tonsils had been operated upon, not one developed poliomyelitis during the epidemic, although in 18 instances, cases developed in the family and in 93 instances, cases developed in the same house. 4 pom CHAPTER VIII Symptomatology. The symptomatology of poliomyelitis corresponds to what one would expect -from a consideration of the pathology of the disease as a general infection, with the lesions most marked in the central nervous system. The clinical manifestations exhibit a widespread and scattered motor paralysis or weakening. The large majority of all cases are of the well known spinal form, but there are many variations in the disease described by Wickman* as types, in which the symptoms are not of the usual kind. His classification and description of these types have enabled us to recognize clearly the multiform character of the infection. Any classification, however, of a disease so protean in its manifesta- tions as poliomyelitis is at best unsatisfactory, as no one classification will cover all cases. Wickman’s classification of the affection into the spinal progressive, bulbar, acute encephalitic, ataxic, meningitic, poly-neuritic and abortive types is comprehensive, but it is open to the objection that it is based both on pathological anatomy and symptomatology. Moreover, it is rather complicated for general clinical use. Mueller’sj classification is simpler, namely that of spinal, bulbar, cerebral and abortive forms. Peabody, Draper and Dochez} advocate a still simpler description, namely, abortive, cerebral and bulbo-spinal. We would suggest the following classification based wholly on pathological anatomy: 1. Non-paralytic or abortive type— Under this head are included cases in which the nerve cells are not sufficiently injured to produce paralysis, though there may be weakness. Under this type also should be classed meningitic cases and those somewhat like tuberculous meningitis but without motor disturbance, often called encephalitic. In these cases, the motor cortical areas are not involved, but there is evidence of disturbance of the sensorium. 2. Ataxic type— Here the motor cells are evidently not involved, but there is a lack of co-ordination, ataxia, nystagmus, etc. The anatomical basis for this is proved by post-mortem findings of involvement of the cerebellum, Clark’s column, and the intervertebral ganglia. This type is very rare. 3. Cortical tvpe— The upper motor neurone is here affected with resulting spastic paral- ysis. This group is also very infrequent. * “Die Akute Poliomyelitis "—Berlin, 1911. + “Die Spinale Kinder Laechmung "—Berlin, 1910. 1 Monograph No. 4, Rockefeller Institute—1912. 197 4. Ordinary spinal or sub-cortical type— Here the lower motor neurone is affected with resulting flaccid paralysis. A manifestation of poliomyelitis difficult to classify is blindness. The most important symptoms of the disease may be described under the non-paralytic or abortive cases, and those of the ordinary spinal form. Non-Paravytic TYPE. Non-paralytic cases are very frequent, and they are often unrecognized and unrecognizable. In some epidemics they constitute from one-fourth to one-half of the diagnosed cases. Wickman found 25 to 56 per cent. of non-paralytic cases in the total incidence of the disease, and he considered these figures far too low. Mueller supports him in this opinion, and believes that the non-paralytic cases outnumber the cases of frank paralysis. The symptoms in the non-paralytic cases include those of general infection, cases with meningeal irritation, cases with much pain, and cases with marked digestive disturbances. The characteristic of the abortive cases, however, is that they are not followed by a frank paralysis. As early symptoms may be mentioned, fever, vomiting, slight diarrhoea or constipation, listlessness, unusual fretfulness or drowsiness. Perhaps muscular tremors or spinal pain may be present. If carefully observed, it is noticed that the child develops slight paralysis of one or more groups of muscles, but instead of continuing, the paralysis disappears within a few hours. Many cases, however, develop no paralysis at all. These cases, nevertheless, are believed to be causes of infection, and it is obvious that their recognition is of extreme importance in controlling the spread of the disease. The diagnosis of poliomyelitis, when paralysis is no longer present or has never been present, may be greatly facilitated by the examination of the spinal fluid and by the use of the biological test for immunity. The spinal fluid, when examined, macroscopically, microscopically, and chemically gives helpful evidence. The biological or so-called immunity test is less practical or reliable, involving, as it does considerable time, and the not. altogether constant performance of a monkey when virus, even of high virulence, is exhibited. If the blood serum of a true case is mixed with virus of known strength and the combined material inoculated into a monkey, failure to develop the disease in such a monkey is considered presumptive proof that the patient’s blood serum contained a substance which neutralized the virus and rendered it inert. If, however, the monkey develops the disease, one cannot positively conclude that the patient has not or has not had polio- myelitis. Both the examination of the spinal fluid and the “immunity test ” leave much to be desired in the way of specificity and constancy of results. 198 ORDINARY SPINAL TYPE. This is the common form of the disease which has been long known and often described, but a summary of its principal features should be given. After an acute onset of greater or less severity, motor paralysis appears, reaching its maximum usually within three or four days. The early symptoms most commonly seen in this type are much the same in all types of the disease, namely, fever, listlessness, drowsiness, sweating, irregular breathing, dyspnoea, hyperesthesia, headache, gastro- enteric disturbance. There is often noticed a peculiar position of the child in bed, one of apparent great discomfort. There may be slight rigidity of the neck, pain on forward traction, with slight Kernig. There may or may not be difficulty of micturition or defecation, and sore throat. Muscular tremors, irregular from fine to coarse, may be observed, especially of the hands and fingers, but also apparent in the entire extremities; weak- ness of the limbs, more particularly in the lower extremities, with early diminution or loss of patellar reflexes; and finally the character of the spinal fluid obtained by lumbar puncture, which, even in the early stages of the disease, is usually characteristic. This fluid, in some cases, at the very onset of the infection, has a peculiar “ ground glass” appearance (to be discussed later), while, in other cases, it is clear and has occasionally a yellowish tint. Microscopically, it shows a predominance of mononuclear lymphocytes. There is an increase in albumen and globulin, and Fehling’s solution is reduced. Later and more definite symptoms are: pronounced weakness of any of the extremities, skin and muscle sensitiveness, spinal pain, rigidity of neck and back muscles, Kernig’s and MacEwen’s sign. The temperature ranges usually from 102 to 104 or 105° until the paralysis is complete, when it falls to normal, by lysis, or, rarely, by crisis. The pulse rate remains high, noticeably higher than the temperature would indicate. But the flaccid motor paralysis and loss of reflexes, may be said to be among the most characteristic symptoms of the disease. The onset, in the great majority of cases, is abrupt, but at times it may be insidious and the disease is ushered in by somewhat indefinite symptoms of an intestinal or anginal nature. A remission of from one to several days then occurs, to be followed by a return of all symptoms and usually by an accompanying paralysis. Fever is often the first symptom. As a rule, there is hyperesthesia or diffuse tenderness over the whole body, which may persist from one week to two or three months. This is, perhaps, most marked in the legs and along the spine. Not infrequently, the first sign of paralysis in the child is noticed by the mother or nurse, after an injury, as from falling from a chair or when walking, etc., so that a history of injury as the cause of the affection may call attention to the disease. While paralysis may, in rare instances, appear two or three hours after illness, clinically it is seldom possible to demonstrate it until three or four days later. A stationary period follows the development of the 199 paralysis, after which begins a spontaneous improvement in muscle power, continuing six months or a year longer. The final paralysis, however, is invariably less than the initial, if the patient lives. The paralysis is more often partial than total, whether of an extremity or of the whole body. Deformities occur. Reflexes are diminished, and also sensation is affected. Disturbances of circulation occur in the severer cases, so-called trophic disturbances, causing the paralyzed part to be usually cold. This, in winter, may give considerable trouble with trophic ulcers, chilblains, etc. Several other types cf the disease have been described, but one type, clinically, is frequently merged into the other. The following six additional types described by Wickman may be briefly mentioned, as they belong to the classics of the literature of poliomyelitis. ProGressivE TYPE. This type, in which the paralysis appears first in the arms, extends downward and finally upward to the muscles supplied by the medulla. When the paralysis reaches the external muscles of respiration (not the centers of respiration in the medulla) death is apt to ensue, and usually on the fourth or fifth day. This is the type which probably was formerly described under the term ““ Landry’s Paralysis ” and is practically identical with it. BurBar TYPE. This type, in which the cranial nerve nuclei are involved, the symptoms depending on which of the cranial nerve nuclei are affected,—facial, abdu- cens, vagus, etc. There may be paralysis of deglutition and the muscles of the larynx. When the vagus is involved, there are disturbances of respiration and of cardiac action. The respiration is at times of the Cheyne-Stokes type. Involvement of one or more of these cranial nerve nuclei is not uncommon in the ordinary spinal type, the resulting picture in these cases being a combination of the two, or bulbo-spinal type. Acute EnceEpHALITIC TYPE. This type, with symptoms resembling those of acute meningitis: the deep reflexes, as a rule, are exaggerated and the paralysis is spastic. Diagnosis is usually impossible without lumbar puncture. This type was discussed by Strumpell, many years ago, under the term “ acute encephalitis of children” but it has only recently been recognized as a variety of polio- myelitis. : Araxic Tyre, ; The ataxic type, of which ataxia is a prominent symptom in most cases. In a few, it is the only nervous symptom, and in others, it is associated with paralysis of the cranial nerves or spinal paralysis. The ataxia is often of the cerebellar type. MEeNiNGITIC TYPE. This type, with symptoms of meningeal irritation, often seen in the early stages of all types of poliomyelitis, but at times so marked that they simulate those of typical meningitis. 200 Pory~NEuriTIC TYPE. The polyneuritic type, in which pain is often an especially prominent symptom, sometimes located in the joints but more frequently along the nerve trunks or indefinite in its distribution. This symptom may be so marked as to cause the paralysis to be entirely overlooked, the affection being mistaken for rheumatism or scurvy. The pain is usually most marked in the paralyzed parts, and the effect produced is that the extremities are often held rigidly and all motion is resisted because of ‘the pain caused. Such rigidity and resistance is possible, of course, only when the muscles are partly paralyzed or some of them are intact, but if the significance of this peculiar combination of flaccidity and spasticity is not recognized, it may lead, in the acute stage, to diagnostic error. Aside from a careful consideration of the general symptoms of the infection, and laboratory analysis of the spinal fluid on one or more occasions during the early or febrile stage of the disease, nothing gives so accurate a basis for diagnosis as a complete neurological examination of the patient. The following is a list of symptoms and objective signs in the order of their frequency, as noted at the time of onset, in 1,500 cases studied with particular care. Beyer Uh He lie A A TR iE aie are ae 806 Nausen and vomiting vc. ois essiians sl so vias sams ais 476 Malaisetandiweakness fehl vo dais en cot sirslale oie 255 Headache Lie ves fo rn aden tah leo cil eitialeinis 205 COnSHPALION 04's «ein abate aisle pd haie uit Wal snk $eik la 148 Ure laBIlIEY oa, ati idee Slaven she siniaie dav we i wih dia 125 Biarshoea wi. Are ahah ties iy vu heiinialers ware 122 Coryza «.is ne aware viene le state mal aR ret gee 78 Rigiditviof neckit. Lo adiuide Billing o in vanity s saints 74 onsite |. oo Lad ie te si i Bite A oi 65 Pharyngitis uuliin tei sles seiie a nsvine on sie wits sian oi 0's 57 Peripheral pain. oii deriv iletiesn seis Jota s van simiais os 57 Muscular twitchingsii: «car yonadis ch siaaiehs as 57 Prostralion ©. oi shies detiimnisnvidin sis vo sidenisioin 49 Convulsions ily... coh catiavade Ve vis cudmimamnnt 2 47 COTO oh it rs aay 1s ediira tains aids Freie ire 45 Among 338 cases at Queensboro Hospital, the cranial nerves were involved in 46 as follows: DEC vin hrs isin ae as iealn bob BT ts buia i edhe dia vite SLAIN Kod inte» 2 OCIOITIOLOT IC. iv sisiaie she Bp 50 viaelniu ies = vieh «wea ein witon ie de 2 Pathetic | us ih teste sf daa s bie s 00 wie siaceinidlei idles 1 ABAUCEHS Cains si thls at id haisia s. nin winis toaiisi mints 'v7e 12 FACIAL cc, alvsieiiis = dis ion wiles iad ales mainie 40 is diate mutate su 26 G10350DRATYNZEA] iis vs sins aisle mate diatevui os minimis ws 2 Hypoglossals se. wie. oh vuda llth dale slat thsi le wishes i Conjugate paralysis of the eyes was noted in 2 cases. CHAPTER IX. Diagnosis and Differential Diagnosis. The diagnosis of poliomyelitis is rarely made conclusively before the appearance of the paralysis. When the paralysis has occurred, the diagnosis as a rule presents comparatively little difficulty, although even when paralysis is present the diagnosis is not always easy. Many cases are undoubtedly incorrectly diagnosed at the early stages of the disease, even when seen in the midst of an epidemic. The principal symptoms which lead to a diagnosis of poliomyelitis have already been mentioned. They may be here divided into subjective and objective symptoms, and laboratory findings. Under subjective symptoms may be listed: those following a history of exposure, including vomiting, pain, difficulty in swallowing, stiffness of the neck, weakness, and very often intestinal disturbances of some kind, pre-paralytic and pre-monitory diarrhoea, or constipation. Under objective symptoms, those most frequently to be noticed are: fever, hyperesthesia, sweating, nervous irritability, stupor, rigidity, irregular breathing, dyspnoea, peculiar position of the child in bed, regional pains usually in the limbs affected, motor paralysis, or weakening, of erratic distribution, most marked in the extremities, especially the legs, and dimin- ution or loss of muscular or tendon reflexes. In doubtful cases of general infection presenting symptoms referable to the nervous system, particularly hyperesthesia, sweating and nervous irritability, recourse must be had to the examination of the cerebro-spinal fluid by lumbar puncture. This procedure is then warranted, and forms our most valuable laboratory aid in the diagnosis of poliomyelitis. Differential Diagnosis. In the first twenty-four to forty-eight hours after its onset, poliomyelitis must be differentiated from the early stages of epidemic meningitis or mild purulent meningitis, and also from a meningism accompanying pneu- monia or other infection. The clinical pictures presented by the above mentioned diseases are quite similar, and it is in distinguishing between them that the examination of the spinal fluid affords the most reliable information. When seen a week or more after onset, cases of poliomyelitis, espec- ially exhibiting cerebral symptoms, must be distinguished from tuberculous meningitis. Though the differential diagnosis of selected cases of early purulent meningitis may be fairly easy, many cases fail to follow the typical description. 202 While epidemics of poliomyelitis usually occur in warm weather, and epidemics of meningitis in the winter or spring, sporadic cases of either occur at any time. A history of gastro-enteritis or an anginal attack, three to four days prior to the onset, is much more suggestive of poliomyelitis than of meningitis. A history of otitis media, an operation in the nose and throat, or a severe injury to the head, with possible fracture of the skull, makes one suspect a meningitis due, most likely, to the pneumococcus or streptococcus. The temperature of poliomyelitis is usually higher at the onset but falls more quickly than in meningitis. There is, ordinarily, greater hyperesthesia in poliomyelitis. The reflexes are more apt to be unequal, and the pupillary reflexes are very seldom lost. In meningitis, there is usually greater stiffness of the neck, and a more pronounced Kernig. Delirium is much more common than in poliomyelitis. A hem- orrhagic eruption or herpes, if present, strongly suggests meningitis. The differential diagnosis between poliomyelitis and meningism is far more difficult, until the underlying cause of the meningism develops. Even then we may be in doubt whether the pneumonia or gastro-enteritis, etc., may not be a complication of the poliomyelitis. In differentiating poliomyelitis and tuberculous meningitis, it is to be noted that the onset is usually sudden in poliomyelitis and gradual in tuber- culous meningitis, but some few cases of poliomyelitis give a history of gradual onset, and occasionally tuberculous meningitis begins abruptly. In the case of poliomyelitis resembling tuberculous meningitis, the stupor is not usually so profound. There is no projectile vomiting, and the pulse is usually more regular, while the temperature declines, and the progress of the case, after the first week or ten days, is generally toward recovery. Quite rarely in tuberculous meningitis, a paralysis may develop in the muscles of the eye. Sometimes other paralyses develop, as of the face or arms, but these are usually transitory. In all these conditions, the differential diagnosis depends greatly on the result of the examination of the spinal fluid, but even here there are no pathognomonic findings. It is by ruling out other affections that it has its chief value, and it is of service only when correlated with a careful clinical study of the case. FINDINGS IN THE SPINAL FLuip. The spinal fluid in poliomyelitis is usually increased in amount and escapes under pressure. It is clear or slightly hazy in appearance and sometimes shows the fibrin web formation, which was formerly considered pathognomonic of tuberlous meningitis. Bedside Tests. Recently, attention has been drawn to the “ground glass” appearance (or a slight haziness seen in the fluid when viewed by a strong transmitted light) as being a help in diagnosing poliomyelitis. The appearance is caused 203 by the increased number of white blood cells (lymphocytes) which are distinctly visible to the naked eye, but better seen with the use of a pocket magnifying lens. It is found chiefly in the fluids containing a large number of cells, and is not so evident when the cells are few in number. The increased number of lymphocytes appear as dustlike particles uniformly suspended in the fluid. These particles can be put into motion by gently shaking the test tube containing the fluid. A normal spinal fluid, or a poliomyelitis fluid which has been standing for a number of hours, and in which the cells have settled to the bottom, does not exhibit this appearance unless the cells are distributed by shaking. It is clear and limpid, as a rule. The examination of the spinal fluid is best made in a dark room with the test tube held against an artificial light. This is not as accurate a test of cell increase as the exact cell count, but it is of practical value as a bed- side test. Any bedside test by which cases of poliomyelitis can be diagnosed dur- ing the early stages of the disease is important, both for purposes of isola- tion and control of infection, and for treatment of the patient. Several precautions, however, must be observed in utilizing this test. First, there must be no red blood cells in the spinal fluid. Red blood cells, if only a few in number, can be distinguished macroscopically by the appearance of the fluid, and the opalescence produced by these cells may be mistaken for that caused by white blood cells. When more numerous, the red blood cells are recognized by a characteristic yellowish shimmer in the fluid. A subsequent microscopic examination should, at any rate, always be made to exclude the presence of red blood cells. “The white blood cells (lymphocytes and polynuclears) are also found increased in the spinal fluid in other conditions, especially tuberculous meningitis, epidemic cerebro-spinal meningitis, syphilitic involvement of the meninges and vessels of the brain, etc. This macroscopical ground glass appearance of the spinal fluid in poliomyelitis, therefore, cannot be said to be pathognomonic, but as a bedside test, provided the precautions above mentioned are taken, it is of diagnostic value during an epidemic. The use of a miscroscope at the bedside is invaluable for prompt diagnosis of spinal fluids in the field during epidemics of poliomyelitis. In the later stages of poliomyelitis, generally after the seventh to the tenth day, the cells in the spinal fluid rapidly decrease in number and soon reach a normal count. In these later stages of the disease it is often im- portant to establish a diagnosis, especially where no paralytic symptoms have appeared. A simple and fairly accurate method of diagnosing these cases is to remove the spinal fluid by lumbar puncture and examine its albumin and globulin content. A majority of persons who have had an attack of poliomyelitis will show an increased amount of both these sub- stances for a period of eight to ten weeks. During an epidemic, especially, after a history of some or all of the pre-paralytic symptoms of poliomyelitis, such increase is strongly suggestive of an initial attack. 204 The attached table illustrates rather strikingly the persistence of the albumin increase (the globulin content generally runs parallel with that of the albumin), even as late as eight weeks after the onset of symptoms. It is interesting to note that the maximum quantity of albumin is found in a larger proportion of cases during the second, rather than the first week of the disease. In the table, + + + indicates the maximum, = the normal amount. In this manner it is often possible to clear up the diagnosis of some non-paralytic types of poliomyelitis even during the later stages of the disease. Albumin Content of Spinal Fluids in Poliomyelitis. Total No. ++ 1 +1 Days Ill. Spinal +++ % and % and % = % Fluids. ++ + 52 8 15.4 22 42.3 18 34.6 4 7.7 39 20 51.3 10 25.6 6 15.4 3 ry 35 12 34.2 7 20.0 11 31.4 5 14,3 31 8 25.8 12 38.7 7 22.6 4 12,9 26 3 11.5 4 15.4 14 53.9 S 19.2 37 1 2:7 8 21.6 18 48.7 10 27.0 51 4 7.8 14 27.5 20 39.2 13 25.5 50 2 4.0 1 22.0 26 52.0 un 22.0 319 + +4 + Maximum. ++ 1, 4+ + Large amount. + 1, 4+ Moderate amount. = Normal amount. In addition to the ground-glass appearance of the fluid, before men- tioned as being of value in the early stages, there is another macroscopic test which may be used both early and late in the disease. This is the so-called “foam test,” which depends upon the pathologically increased quantity of albumin and globulin in the spinal fluids of cases of polio- myelitis. When a test tube is half filled with spinal fluid and throughly shaken, a persistent foam appears on the surface, which may last from one- half to one hour, or longer. The foam thus produced in poliomyelitis is much denser, more voluminous and more peristent than that obtained with normal spinal fluid, but here also the presence of blood must be excluded before making any definite deductions from this test. The needle best adapted for diagnostic punctures has been found to be one of No. 18 gauge and not longer than three inches. Such a needle is easily handled, does not bend, causes little trauma and very little pain. With the patient placed in the proper recumbent position and the back well arched, the needle is introduced almost vertically, but with a slight upward direction, in the median line betwen the third and fourth lumbar vertebrae on a level with the crest of the ileum. Anaethesia, local or general, is unnecessary as a rule. But when the child struggles considerably, and the examination of the spinal fluid is of great importance to clear up the diagnosis, a light ether anaesthesia, for a few minutes, is justifiable. 205 Laboratory Examination. A more complete examination of the spinal fluid must be made in the laboratory, to obtain conclusive results. As before alluded to, the spinal fluid in poliomyelitis shows evidence of an inflammatory reaction; there is a varying increase in the cells and in the albumin and globulin. In some of the cases, this evidence of inflam- matory reaction is well marked; in most cases it is very moderate, while in a few cases, at the other extreme, it is so slight and the fluid produced so nearly normal, that it is very difficult to make a definite statement regarding the findings. In these cases, laboratory technique must be resorted to, to obtain reliable results. The technique employed in exam- ining the spinal fluids in the Research Laboratory of the Department is as follows: All clear or slightly clouded fluids are centrifuged at high speed for an hour. From the sediment spreads are made, taking care to use as nearly as possible the same area on the different slides. The sediments or clear fluids are stained by the Ziehl-Nielsen method for the tubercle bacillus, the sediment of slightly cloudy fluids are stained both for the tubercle bacillus and by the Gram method. Smears from the poliomyelitis fluids are also stained by special blood stains, in order to study the cells. From.this stained sediment we can estimate the increase in cells as slight, moderate, great, or very great. We can also estimate from these stained sediments the per- centage of mononuclear and polymorphonuclear cells and note the presence of endothelioid and polyform cells. The presence or absence of bacteria is likewise noted. Cultures are made from all specimens. Uncontaminated poliomyelitis fluids have been found uniformly negative. The chemical tests used are the nitric acid ring test for albumin, and the Noguchi butyric acid test for globulin. The small amount of albumin and globulin present in the normal fluids is marked,*, +, +1, ++, ++1, +++, etc., representing increasing amounts, and serves as a rough quan- titative estimation of the albumin and globulin. The presence of glucose is tested by using an equal amount of Fehling’s solution and spinal fluid, and it is marked according to the speed and the amount of reduction as —, +, +, ++, +++. The globulin reaction and reduction of Fehling’s solution should not be read for at least half an hour. Taking up these points more in detail, the cytology must first be con- sidered. The increase in cells varies greatly, both in different cases and in the stage at which the puncture is made. Our counts have varied from slightly above normal, that is, from 15 to 20, to 1,000 or more. The counts tend to fall off after the first week and by the end of the second week have dropped to practically normal, in nearly all instances. The cells usually show a preponderance of mononuclears, but, in a few cases there are over fifty per cent. of polymorphonuclears. It has been stated by some that early in the disease there is an excess of polymor- 206 phonuclears, which later are replaced by mononuclears. We found, in an examination of 1,500 fluids, many of which were taken in the 2nd, 3rd and 4th days of the disease, that the polynuclears predominated only in 39 cases, in these instances the fluids being collected on days of the disease from 2nd to 27th. The polymorphonuclears, therefore, in our opinion, represent a definite type of reaction, not a stage of the disease. Often, even in the fresh fluids, the cells are so degenerated that it is difficult to classify them. There have been found large mononuclear cells apparently endothelioid in type that seem to occur more frequently in poliomyelitis than in other con- ditions. The so-called polyform cells are also found. Albumin and globulin, as before stated, are usually increased slightly to moderately. Fehling’s solution is practically always well reduced. The fluids that show a poorer reduction are usually those with the larger amount of albumin and globulin. DIFFERENTIAL DIAGNOSIS OF SPINAL Fruips. Slightly cloudy fluids in poliomyelitis must be differentiated from those in early cases of purulent meningitis, and from the slightly cloudy fluid that occasionally occurs in tuberculous meningitis. The clear or practically clear fluids must be distinguished from rare early cases of purulent meningitis, tuberculous meningitis, syphilis of the central nervous system, especially acute syphilitic meningitis, and meningism. Other rarer conditions might be mentioned, but these are the most important. In the early cases of purulent meningitis, the spinal fluid shows a vary- ing degree of cloudiness, except in very rare instances, when it may be clear. A greater increase in albumin and globulin is usually found here than occurs in poliomyelitis, with a poorer reduction of Fehling solution. The cells, in these fluids of purulent meningitis, are ninety per cent. or more polynuclears, and the etiological organism is always found, except in the mildest cases. In certain mild cases of meningitis, probably of the epidemic variety, the meningococci may never be positively demonstrated in the fluid. In purulent meningitis, due to other organisms, these prac- tically always appear later. In one instance only have we seen a clear fluid from an early case of epidemic meningitis of about eighteen hours’ duration. Although the cellular reaction was so slight, the meningococcus was demonstrated to be present in the fluid by smear and culture. The fluid in tuberculous meningitis most nearly resembles that of poliomyelitis. It is practically always clear, with a cellular increase con- sisting largely of mononuclears, though in very acute cases the fluid may be distinctly cloudy with an excess of polymorphonuclears. Fortunately, in these cases, the tubercle bacillus is usually easy to demonstrate. The number of cells, per cubic millimeter, is usually greater than in polio- myelitis ; the increase in albumin and globulin is more marked and the reduction of Fehling’s solution is not so great. 207 In rare instances, when clinical signs are confusing, when the results of the cellular examination and chemical analysis are indefinite, and it is impossible to demonstrate tubercle bacillus in the fluid, a positive diagnosis must wait upon the results of animal inoculation. The fluid of an acute syphilitic meningitis closely resembles the fluid of poliomyelitis, and the clinical signs are also confusing. The Wassermann reaction is the best method of differentiating the two conditions. Of course, a positive Wassermann would not rule out a poliomyelitis in an old syphilitic condition, but this, combined with the clinical conditions and the progress of the case, makes one reasonably sure of the diagnosis. It was suggested at first that the products of degeneration present in the spinal fluid of poliomyelitis cases might give a non-specific Wassermann reaction. Tests, in about three hundred and fifty cases, have proved this not to be true. The fluid of meningism is clear, increased in amount, and practically always normal in character. The few exceptions to this, found in exam- ining a large number of cases, have fallen commonly into three groups: fluids from cases with prolonged and severe convulsions; fluids in severe whooping cough; and fluids removed just prior to death. In these cases there has sometimes occurred an increase in cells, or in globulin or albumin, or both. In convulsions there is probably edema, in whooping cough, minute hemorrhages, and just before death, circulatory changes to account for'it, Two rare types of spinal fluids sometimes occur in poliomyelitis, when the hemorrhagic process has been more than usually severe. The first of these is of the true hemorrhagic character, the red blood cells being evenly diffused throughout the fluid. When collected in successive tubes, the specimens are all homogeneous, showing no change in the intensity of the hemorrhage. This serves to differentiate it from bloody fluids obtained by the accidental puncture of a vein. Evidence of an older hem- orrhagic condition occurs in the second of these rarer fluids, which having a characteristic yellow color and coagulating spontaneously, illustrates the so-called syndrome of Froin. These fluids occur in other conditions and are therefore not pathognomonic of poliomyelitis. Two thousand poliomyelitis fluids were examined at the Research Laboratory of the Department, but only five hundred of these were care- fully studied. Statisticians state that results based on five hundred speci- mens, and results based on two thousand or more, would, to all intents and purposes, be the same. It seemed better, therefore, to take this smaller number and make careful studies of them, rather than to attempt to use a larger number of specimens and study the data less thoroughly. Tables on pages 228-231 inclusive, show the findings obtained in the laboratory examination of spinal fluids in poliomyelitis cases. 208 CorLoipAL GoLp TEST. Lange's Colloidal Gold Test,* in the hands of some of our workers, has been helpful in differentiating the fluids of poliomyelitis from those of tuberculous meningitis, and from the fluids of meningism, which are not normal in character. This test is as follows: Into the first of eleven test tubes put 0.9 c. c. of fresh, sterile 0.49% NaCl solution. Into each of remaining tubes put 0.5 c. c. of the 0.4% NaCl solution. Add to the first tube 0.1 c. c. of the spinal fluid to be tested. Mix well. Transfer 0.5 c. c. of the resultant 1 to 10 dilution of spinal fluid to the second tube. Mix well. Transfer 0.5 c. c. of the resultant 1 to 20 dilution of spinal fluid to the third tube. Mix well. Proceed in this manner up to and including the eleventh tube. By this method a series of dilutions of spinal fluid is secured, in geometrical progression, ranging from 1 to 10, to 1 to 5,120. Now add to each tube 2% c. c. of Colloidal Gold solution. Shake each tube thoroughly and do not read for 12 hours. The various types of color changes seen in the positive gold reaction are indicated by numerals as follows: Complete decolorization ..............covenennn 5 Pale Dlueiiii viivs oe nashue nals susie s » iw vain sin tie ws 4 BIUE velvet es sina pine eh we a ke 3 Lilacior pUIPle: c. vet vabaissisiiniassissse avs vinninn e 2 Red-DIue «ls viviston sn issiciigle swans via sain s si0i0js 1 Brilliant red-orange—normal color.............. 0 A normal fluid would remain brilliant red-orange color and would, therefore, read 00000000000 or a very slight reaction 11100000000. A poliomyelitis fluid (as found in 78 cases of positive poliomyelitis) would remain brilliant red-orange color in the first two tubes, slightly bluish in third, purple in fourth tube and again bluish in fifth, returning to normal *Note—Zsigmondy following an exhaustive study of the subject of the “coagu- lating” action of electrolytes, or metallic colloidal solution, was able to find a definite measure of the protective action of certain colloids, especially proteins, on the precipitation of gold suspensions by sodium chloride. The degree of protection was specific for each protein he examined. By using this general method he was enabled to distinguish between luetic and normal sera. Lange proceeded further, and found that normal spinal fluids, suitably diluted with a four per cent. solution of sodium chloride, caused no alkalination in suitable solutions of colloidal gold, and abnormal spinal fluids caused partial or complete precipitation of colloidal gold with resultant color changes occurring in curves, which tend to be almost specific for certain diseases, particularly those of luetic origin. This specificity is characterized by maximal color changes within dilution zones. Fluids from different types of menin- gitis give reactions with greatest intensity in higher dilutions. Paretic fluids cause complete flocculation in the first four to six dilutions. Tabes and cerebro-spinal lues give maximal reactions in fourth to fifth dilutions. We have Lange’s results in 105 fluids. Lange's results agree with our clinical and laboratory diagnoses in 103 cases.— Bul. Johns Hopkins Hospital, XXVI, No. 298. 209 red-orange in sixth tube, and would, therefore, read approximately 00123000000. Two hundred positive poliomyelitis fluids tested by the Lange gold reaction in the State Department of Health showed the following values: 11122110000, and there were readings varying all the way from 11110000000 to 12321000000. In other words, the readings given cannot be considered absolute, and the emphasis may shift to the right or left, within moderate limits, but in the main the usual reading corresponds with the readings in a weak luetic spinal fluid. A meningitis fluid unchanged in first two tubes and ranging from this to colorless in the ninth tube and back to original in the eleventh tube, approximately 00112234531. Curves showing these typical reactions and readings are given on pages 211 and 213. Curve I shows the result obtained in Paretic. Meningitic and Luetic spinal fluids. Curves II and VII show various poliomyelitis readings. Chart VIII is the composite of II to VII, giving the average curve fot 90 fluids. QUANTITATIVE CHEMICAL STUDIES IN SPINAL FLUIDS. Quantitative studies in spinal fluids of poliomyelitis and various forms of meningitis have been undertaken in the Research Laboratory, with the hope that these studies would throw some light either on the diagnosis or prognosis of these diseases. The determinations attempted embrace total non-protein, urea and ammonia nitrogen, uric acid, creatinine, creatine, sugar and cholesterol. The methods employed were adaptations, and in some cases, modifications of the micro-chemical procedures so extensively used in blood investigations. Only blood-free fluids were used in these determinations. It might be said, however, that water clear spinal fluids which, on centrifuging, show a fine grayish-white sediment appearing to be totally free from blood, occasionally on microscopic count show the presence of several red cells per c. c. It seems to be impossible to pass through the skin and sub- cutaneous tissues in a lumbar puncture without taking up a few red cells, and these appear to be insignificant so far as the chemical determinations are concerned. : With the exception of urea, which has been extensively studied by French workers (1), quantitative studies in spinal fluids are comparatively meager, due undoubtedly to the fact that until recently, micro-methods not being available for these determinations, any single chemical test required relatively large quantities of spinal fluid and this was not often available. (1) Soper and Granat, Arch. Int. Med., XIII, 131, 1914, review the literature. ~— 210 According to Plaut, Rehm and Schottmiiller, (2) normal spinal fluid contains from 30 to 60 mgm. of protein per 100 c. c. These figures are increased in various diseases extending in meningitis as high as 250 mgm. per 100 c. c. More recent workers (®) report in syphilitic and other patho- logical conditions quantities of protein extending from 20 to 100 mgm. per 100 c. c. of fluid. Total nitrogen in spinal fluids ranges, according to Rosenbloom, (#) from 162 to 362 mgm. per 100 c. c. Woods (®) finds the non-protein nitrogen in spinal fluid about 25 per cent. less than that found in the blood, i. e., about 20 mgm. per 100 c. c. of fluid. This is in agreement with that reported by other workers(¢). The concentration of urea in this fluid, on the other hand, appears to be equal to that of the blood(7). In nephritis, Fine and Myers(8) found that the concentration of creatinine in spinal fluid is 46 per cent. of that in the blood ; of creatine, 22 per cent. and of uric acid, 5 per cent of the respective concentrations of the blood. Schloss and Schroeder (?) recently studied the sugar content in spinal fluids of infants and children, and found that in cases free from meningeal diseases the sugar ranged from .05 to .134 per cent. In cases of meningitis these figures were considerably decreased. The presence of cholesterol in spinal fluids has been reported by various workers (1?) in different forms of paralysis. TorAL NITROGEN. The method employed for the determination of total nitrogen in spinal fluids was a modification of the direct Nesslerization method recently developed by Folin and Denis(11). The modification in detail is presented in another place(12).- In this connection, only a brief outline of the pro- cedure will be given. Two c.c. of spinal fluid are pipetted into a test tube, 1 c.c. of the concentrated acid mixture (containing 1 volume concentrated sulphuric acid, 3 volumes concentrated phosphoric acid and one fifteenth volume of a 10 per cent. solution of copper sulphate) added and the digestion carried out over a micro-burner until the appear- ance of white sulphuric acid fumes; the mouth of the test tube is then covered with a watch glass and heating continued for about a minute. The color obtained is usually straw yellow. After permit- ting the test tube to cool, the contents are rinsed quantitatively into a 100 c.c. volumetric flask, using about 60 c.c. of water in the process. A quantity of 10 per cent. sodium hydroxide is then added, sufficient (2) Leitfaden zur Untersuchung der Zerebrospinal fliissigkeit, Jena, 1913, p. 16. (3) Pfeiffer, Kober, and Field, Proceed. Soc. Exp. Biol. and Med., XII, 153, 1915. (4) Rosenbloom, Biochemical Bulletin, V. 24, 1916. 5) Woods, Arch. Int. Med., XVI, 577, 1915. 6) Millard and Proment, Journ. de Physiol et de Path. General, XI, 263, 1909. 7) Cullen and Ellis, Journ. Boil. Chem. XX, 511, 1915. 8) Fine and Myers, Proceedings Society for Exp. Biol. and Med., XIII, 70, 1916. 9) Schloss and Schroeder, Amer. Jour. Dis. of Child. XI, 1, 1916. 0) Pithini, Zeitsch. f. Phys. Chem., 61, 508, 1909. 1) Folin and Denis, Journ. Biol. Chem., XXVT, 473, 1916. 2 ( ( ( ( ( 1 1 12) Kahn, Journ. Biol. Chem., XXVIII, 203, 1916. ( ( ( Lh” pa —- oo v BE tdi” \N\ y Paretic Luetic Meningitic Normal 55555310000 01233200000 001112345321 00000000000 Curve I. O—MNMD WHO O—-MNMWPUO-—-MNMDUWAUO-NANNO—-—NMNUWHAUAO=—NUWUPUNO=NUWHLW GOLD CHLORIDE CURVES —~ 40Cases near inl igs [ nm a [PD Nt TZ ICS Iololotolo] IL | |ICases AAR EE m 14 Cases x ToT EET ETT IY 6 Cases STOTT eo TetetotalvY 4 Cases CN 4 ~ OTs Era retal 15 Cases rt rere Composite Folie Curve 87 Cases 2B NL TN TT Tell lesToToTSIS1o pvaiil Poliomyelitis Normal Finding Curves II to VIII Inclusive. 215 to neutralize the c.c. of concentrated acid and permit a surplus of 2 c.c. of alkali. Then water is added to make up to volume, and the mixture is filtered. Into another 100 c.c. volumetric flask are pipetted 1 c.c. of the concentrated acid mixture, diluted, 20 c.c. of the standard ammonium sulphate solution containing 1 mgm. ammonia nitrogen and an amount of 10 per cent. alkali solution equal to that added to the unknown. This is also made up to volume, shaken and filtered. Aliquot portions of these filtrates are employed for Nessleriza- tion. Thus 50 c.c. of the water-clear filtrates of both the unknown and standard are pipetted into two 100 c.c. volumetric flasks, diluted to about 75 c.c. with water, 10 c.c. of Nessler solution added to each, made up to volume, shaken, and the colors compared on the colori- meter. The same results should be obtained by using 50 c.c. volu- metric flasks and employing 25 c.c. quantities of respective filtrates for Nesslerization. The total nitrogen in poliomyelitis appears to be in the neighborhood of 25 mgm. per 100 c.c. of spinal fluid. In various forms of meningitis, the total nitrogen was found to be considerably increased, extending from 35 mgm. to about 150 mgm. per 100 c.c. Total nitrogen determination alone, however, are of comparatively little value, on account of the variations of the non-protein nitogen content. This is perhaps well to emphasize, in view of the attempt of Landau and Halpern (13) to show that a certain antagonism exists between total nitrogen and chlorides in spinal fluid; that a high finding of the one corresponds to a low finding of the other. A high total nitrogen may often be due to an increase in the non-protein nitrogen, particularly in the presence of kidney disturbances. Non-Protein Nitrogen, Procedure: To 5 c.c. of spinal fluid in a large test tube are added quantitatively 2 c.c. of a freshly prepared 25 per cent. solution of glacial phosphoric acid. The test tube is then stoppered, shaken and permitted to stand one to twenty-four hours and filtered through a small, dry filter paper. Either 5 or 3 c.c. quan- tities of the water-clear filtrates are used for a nitrogen determina- tion, the procedure being identical with that described for total nitrogen. Urea Nitrogen, Procedure(**): To 5 c.c. of spinal fluid in a 100 c.c. volumetric flask are added about 5 c.c. of water and 0.1 gm. of dry urease, shaken and permitted to stand at room temperature from fifteen to twenty minutes. This is then diluted with about 50 c.c. of water, 2 c.c. of freshly prepared glacial phosphoric acid added, also 0.5 gm. of Merck’s charcoal and made up to volume. This is shaken from time to time and allowed to stand for forty-five minutes or more, when it is ready to be filtered. Definite portions of the water-clear filtrates are used for Nesslerization as in the cases of the total and non-protein nitrogen determinations. The non-protein nitrogen content in spinal fluid is about 50 to 70 per cent. of the total nitrogen, and urea about 60 to 80 per cent. of the non- protein nitrogen. (13) Landau and Halpern, Biochem. Zeitsch., 1X, 72, 1908. (14) Folin and Denis, Journ. Biol. Chem., XXVI, 505, 1916. 216 AMMONIA NITROGEN. The determinations of ammonia were unsatisfactory, because suffi- ciently large quantities of a single fluid required for a test were not available. Mixed fluids, therefore, had to be resorted to. This procedure seemed justifiable, in view of the fact that Frankel-Heiden(1%) was unable to demonstrate ammonia in spinal fluids. The findings show wide variations, with figures ranging from 0.1 mgm. to 9.0 mgm. of ammonia nitrogen per 100 c.c. of spinal fluid. It might be said also that these fluids, although sterile at the time of the determinations, had been kept in the ice box for several weeks, which might slightly affect the results. Procedure: To 25 c.c. spinal fluid were added 3 c.c. of glacial phosphoric acid, mixed, allowed to stand about an hour and filtered; 25 c.c. of the filtrate were pipetted into a 50 c.c. volumetric flask, 5 c.c. Nessler solution added, made up to volume and compared with a standard of ammonium sulphate solution containing 0.25 mgm. nitrogen in 100 c.c. Uric Acip. The determinations of uric acid also were carried out on mixed fluids. Twenty-five c.c. quantities of mixed water clear sterile fluids were used for a test. The Benedict(1®) modification of the Folin and Denis(17) method was employed. The results indicate that there are present from 0.25 mgm. to 0.5 mgm. of uric acid per 100 c.c. spinal fluid. Procedure: 25 c.c. spinal fluid were added to boiling 0.01 normal ascetic acid in a casserole; boiling continued for about a minute; removed from the flame, about 200 c.c. of boiling water added and poured over a folded filter. Filtrate was then concentrated to about 50 c.c., cooled, and about 0.5 c.c. of dialized iron added drop by drop, shaking with each addition. Filtered and water-clear filtrate was concentrated to about 2.3 c.c. transferred quantitatively to a centri- fuge tube, using about 5 c.c. of hot water to wash out the vessel. To the solution in the centrifuge tube was now added about 15 drops of ammonia silver magnesia mixture, allowed to stand for about ten minutes to permit precipitation, when it was centrifuged at a high speed for about 5 minutes. The supernatant fluid was poured off and excess of ammonia drawn off by inverting the tube on filter paper. Two drops of a 5 per cent. solution of KCN are added to dissolve the precipitate, also 1 c.c. of the phosphotungstic acid reagent and about 8 c.c. of saturated solution of sodium carbonate. This is permitted to stand for a minute, transferred into a 25 c.c. or 50 c.c. volumetric flask, depending on the intensity of the color, made up to volume with water and compared with the standard on the Dubosque colorimeter. The latter is prepared by pipetting 5 c.c. of the uric acid standard solution containing KCN, 2 c.c. of phosphotungstic acid reagent and 15 c.c. of saturated sodium carbonate added and made up to the mark with water. (15) Frankel-Heiden, Biochem. Zeitsch., 11, 188, 1906-1907. (16) Benedict, Journ. Biol. Chem., XX, 629, 1915. (17) Folin and Denis, Journ. Biol. Chem., XIII, 469, 1912-13. 217 CREATININE AND CREATINE. For the determinations of creatinine and creatines, the Folin and Denis (18) methods were employed. These methods have been recently criticised by McCrudden and Sargent(1?). The results, nevertheless, seem worth reporting, in view of the creatinine and creatine studies on blood with the same methods. In poliomyelitis the spinal fluids were found to contain about 0.5 mgm. of creatinine per 100 c.c. and somewhat less than this amount of creatine. The recent conclusions of Gettler and Baker (2°) that normal blood contains no more than 0.5 mgm. creatinine per 100 c.c. is of interest in this connection. If the method of Folin and Denis be correct, then it is likely that, similar to urea(2!), creatinine also is equally dis- tributed in the blood and spinal fluid. Procedure: To 5 c.c. of spinal fluid were added 20 c.c. of sat- urated solution picric acid, filtered, and 10 c.c. quantities of the fil- trate were employed for creatinine and creatine determinations, respectively. The standards employed were solutions of crea- tinine (22) in saturated picric acid. The color was developed by adding 0.5 c.c. of 10 per cent. sodium hydroxide solution and allowing to stand ten minutes. Several standards were prepared and the color of the unknown matched with the one which approached it closest in intensity. In the case of the creatine determinations, the standard also was autoclaved. This, it is believed, reduced the chances of error considerably. SUGAR. Sugar was determined by means of the Lewis and Benedict (2?) method, slightly modified. The findings in poliomyelitis are at a somewhat lower level than that of the blood—about 0.06 per cent. In meningitis only traces were found in most cases. Procedure: Four volumes of saturated solution of picric acid were added to 1 volume of spinal fluid, shaken and filtered. To 3 c.c. of the filtrate in a test tube graduated to the 10 c.c. mark is added 1 c.c. of saturated solution sodium carbonate and placed in boiling water for about twenty minutes, after which it is cooled and made up to 10 c.c. with water. The standard employed is a solution of glucose (Kahlbaum) in saturated picric acid. To 3 c.c. of this solution containing 0.5 mgm. of glucose is added 1 c.c. of saturated sodium carbonate solution, kept in a water bath for about twenty minutes, cooled, made up to 10 c.c. and compared on the colorimeter with the unknown. (18) Folin & Denis, Jou'l Biol. Chem., XVIII. 475, 1914. (19) McCrudden and Sargent, Journ. Biol. Chem. XXVI, 527, 1916. (20) Gettler and Baker, Journ. Biol. Chem., XXV, 211, 1916. (21) Cullen and Ellis, loc. cit. . (22) Kindly furnished by Dr. A. O. Gettler of the Bellevue Chem. Labs. (23) Lewis and Benedict, Journ. Biol. Chem., XX, 61, 1915. (24) Compare Myers and Bailey, Journ. Biol. Chem., XXIV, 147, 1916. 218 CHOLESTEROL. An attempt was made to determine cholesterol in spinal fluids by the method recently suggested by Bloor(2%). In no case, however, were the amounts sufficient for quantitative determinations. All fluids tested showed the presence of traces only. Chart I.—Shows the findings in cases of poliomyelitis. Suc- cessive fluids from the same case are indicated by a, b, c, etc. Ap- pended is a chart showing the findings in successive punctures. Chart II.—Shows cases of purulent meningitis, meningococcic, streptococcic and influenzal. Appended is a chart showing the find- ings in successive punctures. Chart III.—Shows cases of tuberculous meningitis with the find- ings in successive punctures. Chart IV.—Shows miscellaneous fluids. Chart V.—Curves showing the percentage of non-protein nitrogen in the total nitrogen. Chart VI.—Curve showing the percentage of urea nitrogen in total nitrogen. Chart VII.—Curve showing the percentage of urea nitrogen in non-protein nitrogen. Chart VIII.—Showing the medium of the total nitrogen, non- protein nitrogen, urea nitrogen, creatine, creatinine and sugar in the various diseases. The medium is used instead of the average, as it is the truer index of the greater incidence of values. It is obvious in estimating averages that a very few high or very low determina- tions will unduly influence the result. PoriomyeLiTis FLuips TESTED. Seventy-four poliomyelitis fluids were tested for six substances: Total nitrogen, non-protein nitrogen, urea nitrogen, creatinine, creatine and sugar. The total nitrogen in 24 of these fluids varied from 16.37 to 34.00 in mgms. per 100 c.c. The non-protein nitrogen in 16 of these fluids varied from 12.08 to 24.78 in mgms. per 100 c.c. The urea nitrogen in 17 of these fluids varied from 5.06 to 26.6 in mgms. per 100 c.c. The creatinine in 22 of these fluids varied from 0.273 to 0.56 in mgms. per 100 c.c. The creatine in 11 of these fluids varied from 0.190 to 0.49 in mgms. per 100 c.c. The sugar in 36 of these fluids varied from 0.025 to 1.00 in mgms. per 100 c.c. The outcome of these 74 cases varied from no paralysis to death, the percentages of above substances found in each fluid gave no indication of the final outcome. (25) Bloor, Journ. Biol. Chem., XXI, 227, 1916. ry CEREBROSPINAL MENINGITIS FLuips TESTED. 219 Successive fluids from twenty-three cases of epidemic cerebro-spinal meningitis were tested with the following result: When patient was improving— Nitrogen decreased. Non-protein nitrogen decreased. Creatinine decreased Urea increased. Sugar increased. When patient was 'dying— Opposite results were obtained. TuBercurous MENINGITIS FLUIDS TESTED. Twelve cases of tuberculous meningitis were tested: Total nitrogen Non-protein nitrogen Urea nitrogen Creatinine Creatine Sugar varied from 20.86 to 34.50 varied from 13.88 to 17.25 varied from 6.66 to 14.18 varied from 487 to .765 varied from .563 to .735 Traces to .060 varied from in in in in in in mgms. mgms. mgmes. mgms. mgms. mgms. MisceLLANEOUS FrLuips TESTED. per per per per per per 100 c.c. 100 cc. 100 c.c. 100 c.c. 100 c.c. 100 c.c. Nine miscellaneous fluids were tested with the following results: Total Non-protein Urea No. Case. Nitrogen. Nitrogen. Nitrogen. Creatinine. Creatine. Sugar. 2821a Meningism typhoid ...vicoishs denne v0 Duke Lila. ane .066 309S5a Meningism endocarditis. . coun. saves oT dulled D0 staan .365 0806 31133 Meningism intestinal trouble. ov ‘coven’ 70 sees a alee "oon 2 .0824 3244s Possible Drain tumor... icons oobi 07 Logan TNs, .350 +0351 31382 Rheumatism.......... ixsovsn 45.25 31.06 14.81 PENS a ? SDS. ad) leh alos 23.35 19.38 * “eine do ype lied oye ty 3251 Cerebrospinallues,. Normal (?) ..... ..... °° .e.cus «373 377 .048 3240 © Normal (2) .icooiiiics + dimuienohy sh A ells CSE edie oti Sal ST ie 3495 Normal. ., «scvvraiicn s inliumen 15.70 ABU69 «wives 1 Peelentl En Balen E SL TOTAL NITROGEN INMILLIGRAMS. wn nn Q 3 2 N3O04.LIN NI3LOdd-NON 40 LN3IOH 3d 100 nN wn PERCENT OF UREA-NITROGEN on Q ~ wn TOTAL NITROGEN IN MILLIGRAMS. Dn 2 A anew MA EE or ly - vem pe ae es sete mp men wpm ee a Ci —————— Rasim 2 : * - . - - 4 pe, # A 5 - - Te ‘ . se - ‘ ig PERCENT OF UREA-NITROGEN nN wn On Oo ~ On 100 TOTAL NITROGEN IN MILLIGRAMS SUMMARY. Total Non-protein __ Urea ing ition Nitrogen Creatinine Creatine mgms. mgms. mgms. per mMgms. per mgms. Aid ‘per 100 c.c. per 100 c.c. 100 c.c. 100 c.c. 100 ope Sugar. Poliomyelitis. .......covvuunn.. 20.0 18.71 11.93 .400 .405 .0611 37 cases 16 cases 16 cases 22 cases 11 cases 36 cases Epidemic cerebro-spinal meningitis ~~ 50.75 26.62 11.60 .476 owh vate Traces 5 : 18 cases 7 cases 9 cases 5 cases hia 5 cases Be Tuberculous meningitis......... 28.10 15.44 7.93 een sive vival at O14 E 8 cases 3 cases 5 cases von maine sete 4 cases | Br Miscellaneous... .... ss vesrives «19.52 AE ry pp .369 EEA .0585 i 4 cases NL J 4cased © ihe .o 6 cases B b 2 5 BP N ETE TNE Cuarr I (A). Total Non- Urea Creatin- Crea- Chemistry. No. Case. iN. ¢: Prot. N. N. ine. tine. Sugar. Albumin. Globulin. Sugar Outcome. 24328 "Pollo: in. 3 le sw ANIL, .515 403 .084 = me aledl: Recovered completely. 25462 Polio ina ae enh .500 .449 .082 + +++ +++ Both legs paralyzed. 23350 GPalio “5. eel Shes Minis Das .492 445 .098 =f 3 ht Recovered completely. 2517a = Polos vo es h 465 .417 .080 “+ + +++ 8 weeks; slight weakness left arm aid hand. 2318s Pollo erat rhe 454 495.092 + = eof Recovered completely. 2682n Pollo eof Su re pageant 4 8S + 3 #++4 26623 «Polio. Nn Teds En A 5080 + + +34 23425 Polio nes ane rH syd les 058 T+ =r defesl Recovered completely. N 2618s Pollo: ir Ton tins eras Voanaie, O12 ++ + ofrelial Recovered completely. ® 20852 "Pollo =. 5) Ces Brendes sie rl 2 00) ++1 +41 +++ Died. 20923 "Pollo 145s 2d Nannie ls FE a .061 + = +++ No paralysis. 84%a PoliO. iis bv arenes tas po aie .087 + +sl. +++ Recovered completely. | 2884n Polo =. ceive in EEE nal hind .055 +1 ++ +++ 4 weeks; weak back. Paralysis of lower exts. ] 2898auPolio oul Sa as . on he .025 +1 +1 +4 -} 12 weeks. Weakness left leg. 20163 ra Palin Ls Se a ne A037 2.100 0602 + + +++ Recovered completely. 3096a POH i, seh a de IRA, 273 hs Traces +sl. he + +1 Recovered completely. 3101a Pollo oe ec A CH ERY DBE Re | i +s. + +41 Recovered completely. 80923 Pollo) o.ni in a .560 he .0742 tt +1 whet Died. 30948 Pollo... nt ae ae .360 Sain) .0523 + + + +1 3106 12 Pol io on™ Ro Be 0 Fe <38%.7:.319 .0753 +sl. +sl. efoto. Left deltoid; Left facial paralysis. 3197 Palio ola Sadia PE .400 314 .0781 offs 24 rg Died. Cuart 1 (B). Total Non- Urea Creatin- Crea- Chemistry. No... .iCase.' N,:. Prot. N. N. ine. tine. Sugar. Albumin. Globulin. Sugar. Outcome. 3236b Polly rin 0k ney 5 ates “O87 448: 0512 + +1 +++ ++ Weak left lower. Brace. 32445 Polio 25.00" 20.93 - 15.68 400. '.314. .0503 + RY +++ 8 weeks. Double pelvic. Brace. 3242h. Polio 122.87 ..... 6.93: 350. .350" 2060 + +++ Post. splints. Weak right ant. tibia. 32485h a Poller "ole. 00 oie ~ 326" wl. .054 +++ +++ +++ Paralysis lower extremities. 299405 Polini i ed SL .609 Late .0613 + ++ +++ Died. 2980h Poliofi Slr alt sly a Vee +378 Lon Traces Al +1 ++ Died. S007a Polio" vw. vr Ceol Le ves .403 shea heii 4 + +++ Recovered completely. 29980 Polio irs hl Ci dae .323 Sts .0595 + + +++ Died. 20079 Pollo i iia ne TE Tai .454 wide .0454 +sl. + +++ 31393 Polio «fi en Lr neon Rall a sre «1003 + + +++ Died. 81405 Pollo: i. 0 id at eT inne at wales .0552 + + +++ Died. 31093 Ploio '*..... Bi sabe aammrete ola ch .0588 S2Ah dPOHO al dS aT eS Tne .396 nh ol .0810 4 pe +++ No definite paralysis. 3106 Polio: i... Gara Ba A290 .0824 + + +++ Left deltoid, left facial. 32744 Polio: = mai ho ra aie oh Kien 0641 + + +++ No definite paralysis. 32073 Polio = ni 5 dn 15.25 5 ne Eh ++ ++ +++ Weak right deltoid. 3282as ‘Polior 17:33: wd ivan Beles Ee stn + + +++ Recovered completely. 3310b Polio 22:72 "14.56 .- . iu.. Te NIE Rn ler + + +++ 8 weeks. Left quad. weakness. 3314b (Polio. "33.30"... Lard: cna CS ails BR es ++ hee +++ Unable to sit. up. Left post. splint. 3313c Polio 23.88 + +... 6.62 a dehy rhe + Ee +++ 8 weeks. Weak lowers; slight weak uppers. Crart:1 (C). Total Non- Urea Creatin- Crea- Chemistry. No. Case. N. Prot.N. N. ine. tine. Sugar. Albumin. Globulin. Sugar Outcome after 8 weeks. 33002 . Polio "21.60. 11.0 ..%..5. Suk Bs Gg + = +++ & weeks. Abdominal muscles relaxed. 3307h Polin 124.28 J i.. lta, Deen Sine i he ++ +1 +++ Recovered completely. 3322b. ‘Polio .iu.. «Serves 12.50 os wn Crier aa ae + +1 + +1 +++ 8 weeks. Left facial paralysis. 3327c Polio “....., 13.72 «vivid ea Er finn, + +++ ++4++4++ +44 Recovered completely. 3331a Polio 34.00 20.66 $35 ..ak Fath irl wpe fn =} rjisfle ied. 3324b Polio“... =. 16.34 I... Hos re tas ++++ ++4++4++ +++ Left deltoid weak. 3341. “Polio 30.00 ..... 18-51.'~ J... ert ye vm +4 += +++ Recovered completely. 3342b Polio’. ,’.... 1213: ar Ay Eb Eee he he +++ No definite paralysis. 3343b Polio ..... 12.08 ..... red SEA Eh ~+sl. + +++ No paralysis noted. 3354n Piola lt toi ee 14.36% ne Bria Taiey Seis ++4++4+ +++4+ +++ No definite paralysis. Weak gluteals. 3357b :. Polio 222.57. 16.64 = ..... ahs Liter prt ++ +1. +++ 3359c Polio’ 26128 ‘Loin, Ra 2h CES Rovers +1 +1 +++ Weak right gluteals and tight lumbar muscle. 3196d Poilo 19.50 15.54 13.12 AT SAE 8 Ps +1 ++ +++ Left deltoid. Left facial paralysis. 33584 “Polio... HOt 0 ch tel Oe ei +l +++ 8 weeks. Post. splints. 3361c. ‘Polio. ..4:. 17.87 in. Eis env Lol +4 i =} Died, 3310c Poligic oui sila 9.61 en a Sr +1 ++ +++ 8 weeks. Weak left Quad. 3376c Polio A842 =. 7. wd Seen fiat) Cebree he +sl +44 Recovered completely. 3322¢ ‘Polio .-,.... 12.38 ~~. 7... hada Juhi Ah Gees ++ hee +++ Paralysis left facial. 8 weeks. 3300b Polio 20.61 ..... 7.31 os i Sse +1 +1 +++ Relaxed abdominal muscles. 8 weeks. Slight facial paralysis. 3379 Polio 16.87... ol das MAERE lb PGR RY fe +++ Slight weakness. Both Quad. ext. 0£2 Crart I (D). Urea Creatin- Outcome. Chemistry. Sugar. Albumin. Globulin. Sugar. ited SE =a ott Ey offs ==} 1 i Jr ran i ~-l 1-4 eas + sl. +44 dl +1 +1 +++ rahe +1 +++ nies +1 +1 +44 era + tobd hell ais alae i +4 sd ete tot =o] i= isis + +d. +44 .0523 +1 ee +++ vox eons += = +++ sp. Died. No definite paralsyis. 8 weeks. Weak thigh and back muscles. Right arm and leg paralyzed. Paralysis left Quad. ext. Recovered completely. Ri deltoid paralyzed. ied. Died. Died. Died. 1€e . \ . . a Successive Punctures in Cases of Poliomyelitis. Total Non Prot. Creat- N. N. ine. Sugar. 3274 ist Punct........... .0641 2dPunct......n. 00 oo in .0810 3d Punct... 0 21.42 : . 3196. Ist Punct........... v's ule .319 0753 2d Punct.... v.00 Jen lete ais .0824 4th Punct.. .... .vv. 4s 19.50 15.54 3s win 3310. 2d Punct....-... a 22.92 14.56 8d Punct.'......0... AL 3s 3300. fst Punct........... 21.00 11.0 2d Punct:......... 20.61 3322. ed-Punct.;.. ci... Wns i 3d Punct.....00 0 he 17.85 3324. 2d Punct...c.. 0 Tn 16.34 Sd Punct............ 20.68 wasn 3341. 2d Punct....... 0... - 30.00 a 3d Punct......:...., 5 15.88 Non- Total Prot. Urea Crea- Crea- Out- Case. N. Ni: tinine. tine. Sugar. Globulin. Sugar. come. EeCeS MM. 5e vs aanivin y Traces ++++ ++++ ++ Recov'd. BoCe Se Mu alanavsisinuvimmns tiie sos + +4 no reduct. Recov'd. E.C.S.M.. 45.15 ...... 14.12 +++ +++ + ++ Recov'd. E.C.S.M.. 34.25 -15.86:.... -+ 4 -+ + +1 Recov'd. E.C.S.M.. 62.20 4..... 10.25 tpfe pbc feof feels Tofe Died. E.C.8. M.. 24.46... cone viv vs ++4+++ +4++4++ ++ Recovd. E.C.S.M.. 39.80 «.. us vives + 4+ +444 = Died. E.C.S.M.. 120.00 33.47 21.62 +444 +4+++ + Improv. EC. S. MM... “36.75... . ours +++ +44 ++ Improv. E.C.S. MM... S0.00 «i widen ———— ———— — Recov’d. E.C.8.M.. 33.18 «viv. swat + Recov'd. E.C.S.M.. 95.00 45.83 36.48 ++++ ++++ - Died. E.C.S.M.. 47.15 126.52:.:'9.20 +4+4++ +++4+ + Recov'd. E.C.S.M.. 43.45 21.93 11.60 ++4+++ 4++4+++ +++ Recov'd. E.C.S.M.. 250.00 136.25 $53.28 +++4+ +4+4+4+ - Died. E.C.SM.: seereeCinnve vin +444 +A++4 = Died. EC. So M.t iin, hence sis depts At = Died. E.C.SSM.. 73.530 26.60 ...:. ++4++4+ +++1+ = Died. Influenza... 40.25....... 6.28 +4++4+ +4+++ - Died. Influenza... $38.75 ive ilihinns +4+4+ +4++4+ - Died. Influenza... 51.50 ....os wre +4++4+ +4+++ = Died. Strep. Men.. 86.30 ...... 11.10 +4+++ ++++ - Died. 233 Successive Punctures in Cases of Epidemic Cerebro-spinal Meningitis. Total Non Prot. Urea Creatin- Creat- N. N. N. ine. ine. Sugar. 3441. 2d Punct....... ov. s 120.00 33.47 21.62 Sth Punct... x.vn..s 36.75 io at 3473. Ist Punct..’.i ol iaoiy 50.00 2nd Punct.... 0... 53.75 5% 25 us Ath Punct.... veins 47015 26.62 9.20 Sth Punct... : vs res 43.45 21.93 11.60 3487. ist Punct........... 93.00 45.83 36.48 2d Punct......0ic. ous 250.00 136.25 53.28 3044. 4th Punct..... at xen 73.50 26.60 pind 535 .704 Traces Sth-Punety.... v.00 ai thy ers A 476 rtd Traces 6th Puneet... ...%.. 0s ces oe vie .476 et) .0628 4332. Ist Punch. :. cu dinn: 40-25 dash 6.28 3d Puncticvvu savers 138.75 Hears ide CHaArr III Non- Total Prot. Urea Crea- Crea- Out- No. Case. N. N. N. tinine. tine. Sugar. Albumin. Globulin. Sugar. come. 2S08h TT. Bo Men... conse s ovo Aguile .487 .563 .060 ++ +++ +++ Died. 24000 SDB, Men. Li ins uvaian liietes L768... 738 028 wt ofc} + 31153 Ti B. Men... wivas wiive wenn amtesis ana LrACES: inp=l ++ +sl. Died. 20063 TT. BoMeN ur oivoins sais ltaiimeiy cee Lr ye at DFACES. | elonls + +1 + +1 Died. 3284a.°T.B. Men, , 34.50 ...., 6.66 iy, Cea T ++ +, +4 = Died. 3333a T. B. Men CE SO Se EE A Gr LE ttt 44+ 4 3284b T. B. Men 20.70 47.25 7.93 cuni marie tecis ++4+++ +++4++4+ +44 Died. 333352 YT. Bs Men... 42.50... 1438 Nid i ee be +4+++ ++++ = 3434a T. B. Men 24.380. La RE SEED ++ + +4 + Died. 3284c T. B. Men 20.50 13.88 7.006. nw. 0 ured iiiineeias fein cof tripe oe +4 Died. 34093 T.BaMen. . 25.25 15.44 0.0 he i ta ahiiinety wr hate ofp. Soe elo wef SEL LCD OA, 347805 TT. B Men... 20.80 o.oo v8 tins eens ddr Spt ++ Died. Case of Tuberculous Meningitis. Total N. Non. Prot. N. Urea N. Creatinine. Creatine. Sugar. 3284. 1strPunct. 0. oan 34.50 Side 6.66 2d Punct.-.5 aon 29.70 17.28 7.93 Ja Punct. on. 0k 726.50 13.88 7.06 CHaArT IV. No. Case. Total N. Non Prot.N. Urea N. Creatinine. Creatine. Sugar. Albumin. Globulin. Sugar. Outcome. 2821a Meninglsm typhold. ;.c.oviive’ wii damn Tein vy .066 + + +++ No paral. 30932 Meningismendocarditis. ..... s3t.v Sliiarnt aie at .365 .0806 a zie +++1 Died. 31136 Meninglsm intestinal trouble... «oven 0 nas St vase ish .0824 +sl. +sl. “+++ Recovered completely 3244n ‘Possible Drain tlimor. .... . ool | dees br a Ls i 1 nu .350 .051 +++ +++ +++ 2138a Rheumatism................ 45.25 31.06 14.81 Gay. pate ay bate + + +++ ? SYDIIS oes vrnny pwiew sales 23.35 19:38 a... ele mia 0 eae 3281a Cerebro-spinal Iues. . .uusinvn shivas’ Fwesst. | i secas .373 L377 .048 + +sl. sreltals Improved. 32402; Normal 42) hussein sinicsing 18.3500 ni cis Rian athe Frat HE A + == +++ Recovered . completely 3408 (Normal. a. do ved Vivi c siha 15.70 13069: A Tt an a rate aden Poin = + +s. +++ g 235 CHART V. Relation of Cell Increase to Outcome. (Condition After Approximately Eight Weeks.) Weakness or Complete Recovering Cytology. Recovery. Paralysis. Paralyzed. Dead. Lumbar Puncture No increase. ..:..5.+.5, 9 0 4 3 in 1st week of Shght ciszics voirnan 57 20 34 26 fliness.......0.... 354 Moderate............ 50 10 25 29 Greats. ne ata ns 35 11 23 18 Second week.... 103 No increase.......... 0 1 2 2 SHAht, vs nies 18 9 18 5 Moderate... 0... 0... 13 2 4 11 Great. i... cov. vendre 7 4 5 3 After 2d week... 43 Noincrease.......... 1 1 0 0 Sahib coos vaiss 10 1 12 4 Moderate... ov: ois 3 2 6 1 GTBAL. te os Saiiuobe 2 0 0 0 500 207 61 130 102 1 CuaaArT VI Relation of Condition at Time of Puncture to Outcome. (Condition After Approximately Eight Weeks.) Condition at Time Weakness or Complete Recovering of Puncture. Recovery. Paralysis. Paralysis. Dead. Lumbar Puncture No signs of Paralysis. 25 2 1 3 in 1st week of Weakness orother illness. ....... 354 marked symptoms... 108 25 30 34 Paralyzed in some part 18 14 55 39 Second week.... 103 Nosigns............. 6 1 T 0 Wealmess, os... vives 28 8 7 s Paralyzed: iio ovis 6 7 18 16 After 2d week.... 43 Nosigns............ 2 0 0 0 Weakness. .......... 11 1 1 3 Paralyzed........... 3 3 Y 2 500 207 61 130 102 CuArt VIL Five Hundred Cases—Types of Cases. CYTOLOGY. ALBUMIN AND GLOBULIN. OUTCOME. Cases. "No Increase. Slight. Moderate. Great. = + +1 ++ +41 +++ ++++ OX. Weak. Paral. Died. Chase l........ 234 13 96 76 49 13 118 47 36 10 6 4 "173 29 17 15 Class IV...... 264 10 114 81 59 4 108 606..::53 11 18 4 32 32 113 87 Chess’ ll....... 2 0 1 1 oh oe 1 1 Sie os ho, . 2 500 23 211 158 108 17 227 114.39 21 24 8 207 61 130 102 CuarT VIII Relation of Condition of Puncture to Findings. No Increase. Slight. Moderate. Great. se + +1 ++ ++! +++ ++++ Nowparalysis. 0.00 aids 41 5 15 15 6 2 26 6 3 1 1 2 With weakness. ................ 261 11 102 83 65 12 121 54 50 13 8 3 With paralysis. ........-..500 0; 198 7 94 60 37 3 80 54 36 7 15 3 500 23 211 158 108 17 227 114 89 21 24 8 9¢Z Relation of Day of Puncture to Laboratory Findings. Cuarr IX. Cytology. Chemistry. Day of Puncture. No Increase. Slight. Moderate. Great. a 4 +1 ++ +41 +++ ++++ 4 ree Ce Ta rr = 1 2 1 .. 1 i oe bn a ts 2: 2 22 17 1 2 30 13 3 2 1 1 Sac s wali € deity EY 2 16 14 20 3 20 14 11 1 2 1 Beas «varie Vigts le any ins Sek 4 29 22 12 2 37 17 9 2 we ve S.. 3 24 30 20 2 34 14 20 4 2 i 6. i in Sana a ede ey ves 3 25 11 11 1 28 11 8 io 2 aie dr Sk a an er a 1 16 13 8 1 16 it 7 1 2 os Sr Ale uly iin Fed RS are 12 8 7 1 10 5 6 1 4 ee fe Gal ait SH ER 8 8 4 1 12 4 2 1 os 5 10 EA A es ts 2 7 6 "an 1 3 4 4 ee i 3 Bh se a es dh SM 1 3 2 3 “ 1 5 2 x 1 > 12 an eR eT 10 3 2 1 5 3 1 1 3 1 3 i a a nea ae 1 4 4 2 1 3 1 3 i 2 i 1 EA AR Dine al LUI Str ag ene) 1 3 1 i i = 2 2 2 on = 15. non eae Ben hl a 3 2 - os 1 1 3 o3 oh oi BG ere eae ANE ine veni S ore arena ake 2 5 or he gs o 1 oe 5 1 Nit ne ew Chien 5 he in oe 4 24 1 he oF vr A a Ra a A Tek ht 1 A 5 3 at «it 1 oh 10.0 0 a YL Veen he 1 1 4 3 1 1 4 ie BR a 2 ok i os 1 2 y % 1 A RE ale et 2 3 1 o% 2 1 2 1 ie RS ni Se ae hil en) 5 1 es “i oe 1 = bis ve I I Al eb ls eal 1 5 oe i oi £ Az ce i re Nea aa 1 i vie Al od 1 os = 275 1 os So 1 ve 4 x SE Ge ee 1 lf is os 1 a Te 30 rn ro A re he 2 1 1 1 2 = 1 3S ee an Wee Y 2 1 fi PAs 1 oi 1 1 dO ia Tare ade x ent Ted 1 1 2 He py AL a 1 oe 5; 1 A300 la ie as ne ya 1 By 1 o A LB ina Ey Ie 1 1 30: sh rede 2 1 2 1 *33 211 158 108 17 227 114 89 21 24 8 2241 207 +4 15147 104+4 21849 11341 8742 1843 2341484+16=7500 * 16 cases day of puncture uncertain. LET 238 CaART X. Relation of Cytology to Chemical Findings. Albumin and Globulin. Cytology. ss i +1 feels spel. piel erties ol No increase. ... 23 1 12 7 3 0 0 0 Shight..-.-... .. 211 9 105 39 35 9 11 3 Moderate... .... 158 5 73 35 31 5 6 3 Great. i ....... 108 2 37 33 20 7 7 2 500 17 227 114 89 21 24 8 General Accuracy in Diagnosis. Although, at the outset of the epidemic, the medical staff of the Health Department was, for the most part inexperienced in the diagnosis of poliomyelitis, the percentage of errors made by the diagnosticians was extremely small, considering the difficulties they had to contend with. The following study of 4,474 cases, received and treated in the Depart- ment Hospitals, shows the result of the diagnosis arrived at. Of the 4,474 cases, 96 cases, after being observed for some time in the hospital, were discharged as “no illness.” In 49 additional cases, the patient's disease proved to be other than poliomyelitis. Disregarding the 96 cases sent in for observation as a matter of precaution, it appears that actual errors in diagnosis occurred only in 1.5 per cent. of these cases. None of the 96 patients held for observation developed any sickness within a reasonable time after leaving the hospital, and in no case did poliomyelitis in the patient or any member of the home household follow. The final diagnosis in the 49 cases above mentioned, which were found not to be poliomyelitis, were as follows: In 6 cases there were convulsive manifestations: Hysteria (2), uremia and nephritis (1), tetany (1), epilepsy and arthritis (1), chorea (1). In 15 cases there was meningeal involvement: Tuberculous meningitis (8), streptococcus meningitis (1), cerebro-spinal menin- gitis (3), pneumococcus meningitis (1), meningism and gastro-enter- itis (1), influenzal meningitis (1). In 13 cases there was paralysis or deformity: Rhachitic pseudo- paralysis (1), cerebral thrombosis (1), post-diphtheritic paralysis (2), seven-year-old poliomyelitis (1), Pott’s disease with kyphosis (1), congenital calcaneo-valgus (1), Bell’s paralysis (1), congenital tetanoid pseudo-paralysis (1), hemiplegia (2), transverse myelitis (1), cerebro-arteriosclerosis and traumatic supra-orbital neuritis (1). In 6 cases there were respiratory systoms: Pulmonary tubercu- losis (1), purulent pleuritis (1), broncho-pneumonia (2), broncho- pneumonia and pertussis (2). In 8 cases there were acute infections or other acute disorders: Purulent peritonitis (1), intusussception and gastro-enteritis (1), dentition (1), cervical adenitis and cellulitis (1), malnutrition and spasmophilia (1), pericarditis (1), septic arthritis (1), measles (1). In 1 case there was idiocy. 239 It is apparent that the symptoms of many of the conditions here enum- erated so closely resemble those of poliomyelitis that, for this reason, prompt differential diagnosis was often impossible. The proportion of cases manifesting meningeal symptoms is striking ; the same is true of the number of acute infections with respiratory symptoms. } Again, in a special investigation made of 1,500 fatal cases reported by private physicians as due to the disease, a comparatively low diagnostic error is also recorded. Of the 1,500 total cases, a positive diagnosis was made in 1,355 cases; 145 cases were diagnosed as “no illness” or “undetermined.” In 35 of the 145 cases no diagnostic report was obtainable, and therefore they are not included. Of the 110 cases remaining, 46 were reported as “no illness,” leaving 64 cases “undetermined.” Altogether, incorrect diagnoses were made in 52 cases out of the 1,355, making an error of 4 per cent. The conditions other than poliomyelitis for which they were incorrectly diagnosed were: Pneumonia, pulmonary edema, gastro-enteritis and cerebral hemorrhage. As direct cause of death, in those cases, was given: Respiratory failure in 828 cases, or 61 per cent. ; cardiac failure in 452 cases, or 33 per cent.; and both respiratory and cardiac failure in 23 cases, or 2 per cent. The diseases mistakenly diagnosed as poliomyelitis were: Cerebro-spinal meningitis, tuberculous meningitis, pneumonia, gastro-enteritis, post-diphtheritis paralysis, dysentery and pertussis. The results here mentioned are further corroborated by a more recent study of the total number (9,050) of cases occurring in the city during the twelve months of 1916. Of the 9,050 cases, 240 were discharged by the diagnostician as being incorrectly diagnosed poliomyelitis, making an error of 2.65 per cent. DiagNosTIC PROCEDURE. In this connection, it may be interesting to describe briefly the outline of the procedure in diagnosis which was carried out by the diagnosticians during the 1916 epidemic. Early in July, the Chief Diagnostician received instructions to visit hospitals throughout the city, on request, and to discharge as not contagious those patients whose history and clinical condition at the time of admission, and subsequetly, did not justify a diagnosis of poliomyelitis. Later, about August 1st, these instructions were issued to Borough diagnosticians also. Throughout the entire outbreak the regular procedure was followed in the homes, the Chief and Borough Diagnosticians confirming or reversing diagnoses in doubtful and disputed cases. It was evident at the outset that, to do this work satisfactorily, some definite criterion, some irreducible minimum of evidence must be established, in the absence of which diagnosis of poliomyelitis could not be sustained. To illustrate: with the exanthemata, for instance, it is essential to have, in some form, evidence showing the existence of eruption—past or present— furthermore, it must persist for an appreciable time, certainly not less than 240 forty-eight hours. Cases “ sine eruptione ” arise from time to time, requir- ing isolation, but positive official diagnosis of exanthematous diseases, without any knowledge of an exanthem, cannot be made with safety. Equally, in the diagnosis of poliomyelitis, while the mild, or non- paralytic or abortive case is constantly to be kept in mind, there must be evidence of some abnormal condition, past or present, more definite than the general symptoms of fever, gastro-intestinal disturbance, or rigidity of spine. The essential condition in this disease, from the standpoint of the clinician, undoubtedly is impairment of motion. If, in any given case, the disease be so mild, or abort so quickly and completely that the musculature remains wholly unaffected, then that case must fail of positive clinical recognition. Moreover, all the evidence goes to show that paralysis or weakness once present, invariably persists for at least one week. No patient was discharged until examined by at least two physicians; until several days intervened between the date of discharge and the date of the original diagnosis, and (in hospital cases) until the history previous to admission was investigated. No patient showing positive lumbar puncture findings was discharged as not contagious. In some of the cases discharged a positive diagnosis other than polio- myelitis could be made ; and in others no diagnosis was possible, the patient showing nothing abnormal or a febrile condition only. Any recognized impairment of motion, let it be ever so slight, coming on recently and not otherwise to be accounted for, held a patient as affected with poliomyelitis. The presence or absence of reflexes and electric tests were not found to be of much aid in reaching conclusions. By following out the foregoing procedure, a high degree of diagnostic accuracy was thus obtained during the epidemic, as shown by the figures already given. CHAPTER X. Prognosis. In poliomyelitis, more than in any other disease perhaps, a distinction should be made between prognosis as to life and prognosis as to complete recovery of function. But in predicting the outcome of such a multiform affection as this, either as to life or function, we should be very guarded in our opinions. Before the disease was well known it was an accepted axiom that in- fantile paralysis, or poliomyelitis, was seldom if ever fatal, and that the paralysis which followed was invariably permanent. That this disease can, and often does, end fatally has been clearly shown by the history of past epidemics ; and it has been frequently demonstrated by clinicians in various parts of the world that complete recovery from paralysis is not only pos- sible, but by no means uncommon. The prognosis as to life is based on mortality statistics and upon the extent of involvement and direction of advance of the lesions in the brain and spinal cord. But the mortality of poliomyelitis varies greatly, both in different epidemics and in different centres of the same epidemic, and even in different points in a single center. In some localities, epidemics have shown great virulence, while in others they have been very mild. On the whole, it would appear that the mortality of European outbreaks (see table No. 1 in the appendix) has been fairly high, higher than that reported in the majority of American outbreaks. But the mortality at different times and places has fluctuated considerably, and also in the same place. Thus in the New York epidemic of 1907, the case fatality is estimated to have been 5 per cent.; in the 1916 epidemic in New York, it was 26.9 per cent. Moreover, it should be borne in mind that the death rate in an epidemic depends upon the number of cases reported, and in an epidemic of polio- myelitis on whether the non-paralytic or abortive cases are estimated or not. Even when these latter cases are estimated, the mortality changes according to the thoroughness with which the estimation is made. Since a great many cases of this disease are of the non-paralytic or abortive type, which are often unrecognized and unrecognizable and therefore not estimated, whereas the severe and fatal cases are usually reported fully, the death rates in polio- myelitis should be considered as approximate only. For this reason, also, the prognosis as to life, as expressed in mortality tables, is probably more favorable than the recorded figures would seem to indicate. Although children, as a rule, are more commonly affected than adults, in many epidemics, the mortality has been reported as being highest in adults. In most of the recorded epidemics the case fatality has been greater from the age of ten years upward. In the epidemics, on the other hand, in New York, in 1907 and 1916, the death rate was higher among children in 242 the first five years of life, and after the fifth year the mortality steadily declined. Among older children and adults it was very low. When death occurs in an acute attack, it is due, as a rule, to involve- ment of the muscles of respiration, and although there is no uniformity as to the danger of the diseases upon any particular day of the disease, life is in greatest peril, apparently, between the third and seventh days— the fourth and fifth days being perhaps the most fatal. After the seventh day the prognosis as to life is generally more favorable. Any involve- ment of the muscles of respiration or deglutition increases the seriousness of the prognosis and recovery is uncommon in the bulbar and ascending types of the disease and in the encephalic types. Regarding prognosis as to function, we must be still more cautious in our predictions, especially in the early stages of the disease; and even in the later stages, it is unwise to make any dogmatic assertions as to ultimate complete recovery of function. In general, a severe onset is more unfavor- able than a mild onset, but this is not true of all cases; for at times a severe onset may be followed by complete recovery of function or mild paralysis, and a very mild onset by severe or extensive paralysis. Suffice it to say, prognosis as to function is usually more favorable in cases of mild onset, and in all cases complete recovery from paralysis occurs much oftener than was formerly supposed and depends to a great degree upon the intelli- gence and persistence of expert orthopaedic and neurologic after-care. After the onset, in most cases, a period of spontaneous improvement takes place, beginning with, or slightly before, the disappearance of the tenderness, and progressing toward complete functional recovery. This spontaneous improvement may last some six months to a year or more. Most of the complete recoveries occur in the first half year, but some occur during the second half, and a few cases are reported to have recovered from paralysis, by prolonged treatment after several years. Sufficient data are not available from the recent epidemic in New York to give full comparative figures as to the proportion of complete functional recoveries to permanent paralysis which may occur. But the results obtained in the Health Department hospitals, in the care of polio- myelitis patients, may serve as a type of the prognosis of the disease as it was observed in the city when the cases were properly treated. Of 3,441 cases treated, in the four Department hospitals, 716 died, giving a mortality of 16 per cent. Of the cases discharged after tieatment, as wholly or partially recovered, 1,223 cases were discharged with “no visible paralysis,” and 2,526 cases were discharged with “ visible paralysis.” In other words, 32.6 per cent. of the cases treated showed complete func- tional recovery, or had not shown paralysis at any time in the course of the disease, while 67.4 per cent. showed remaining paralysis in some degree. Of 2,715 cases followed up carefully in the homes it was found that 1,885 had a serious paralysis of one or both lower limbs, and were unable to walk; 243 530 more were partially paralyzed in the lower limbs, although still able to walk; 273 had one or both arms totally paralyzed. It should be noted, however, that the average number of days per patient during which these cases were under treatment at the hospitals was 32.4, or scarcely more than a month; none was under treatment for two months. It is now known that marked or great improvement may be induced in paralyzed cases by correct treatment, at a much later period than was formerly credited. We have every reason to believe, therefore, that the cases which still remained paralyzed after such a short treatment in the hospitals would, with a prolonged treatment for a period of six months or more, show a larger proportion of complete recoveries of function than here given, and that the deformities, at least, in these cases would be greatly lessened. This belief is all the more reasonable because the large majority of the patients treated were under ten years of age—as indeed were most of the cases occurring in the city—and according to all authorities on the disease (Wickman, Leegaard, Lovett, et al.), age is an important factor in prognosis; the prognosis as to recovery of function is considerably more favorable in young children than in older children and adults. What has been stated concerning the prognosis of the cases treated in the Department hospitals may be considered as approximately true for all cases occurring in the city in which there was suitable treatment. The results of the 1916 epidemic have taught us many lessons, but one of the most valuable of these relates to the prognosis of poliomyelitis, namely, that though this is undoubtedly a serious epidemic affection, the prognosis of the disease, both as to life and as to function, is by no means so unfavor- able as is the case in several other acute infectious diseases with which we have been more familiar, but which, on this account, we have held in less fear and respect. CHAPTER XI. Record of Treatment Employed. TREATMENT IN HEALTH DEPARTMENT HOSPITALS. Inasmuch as more than one-half of those living twenty-four hours after the onset of poliomyelitis were treated in the hospitals of the Health Depart- ment, unusual opportunities have been afforded for the clinical observation and study of the disease. : In the treatment of these cases particular attention was paid to serum therapy, especially with human serum, in the hope that it would give favor- able results; to intraspinal injection of adrenalin based upon physiological deductions and endorsed by one of the best known physiologists in the country ; to mechanical means of maintaining respiration in cases of respira- tory paralysis; to the internal administration of antiseptics (urotropin) ; and to orthopedic treatment, in paralyzed cases, by mechanical supports, plaster dressings, braces, etc. The treatment of casés may, for purposes of description be divided into (1st) symptomatic; (2nd) supporting; (3rd) antiseptic; (4th) physiologi- cal; (5th) serum therapy; (6th) hydro therapy; (8th) orthopedic. 1. Symptomatic Treatment— This was largely devoted to the alleviation of pain, a constant and depressing symptom in the first week after admission. For this, anodynes and hot water baths were found to be most efficacious in giving relief. An- other cause for symptomatic treatment was dyspnoea, for which mechanical appliances were used. Many forms of apparatus were tried, but the only measure that seemed to yield definite results was the carefully supervised inhaling of oxygen under pressure, with the ordinary inhaling cone. This method relieved the dyspnoea and allowed the pulse to regain its strength in a shorter time than did any other method employed. 2. Supporting Treatment— This included, principally. the administration of food in proper amounts. A large number of the patients admitted to the hospitals suffered from paralysis of the muscles of deglutition; and only by the most careful super- vision of the administration of the proper quantities of food were the patients kept alive. These cases demanded constant medical attention and nursing. In cases of long standing, tonics were given when indicated, but such cases were comparatively few in number. 3. Antiseptic treatment— This consisted of the administration of urotropin more particularly. At one of the hospitals of the Department, namely, the Willard Parker Hospital, 245 urotropin was used throughout the epidemic; at another, the Riverside Hos- pital, it was but little used. As far as any definite effects were observable, the cases seemed to do equally well with and without its use. Under antiseptic treatment may also be included those prophylactic measures which were employed for the protection of nurses, doctors and others, in attendance upon patients. At the beginning of the epidemic it was recommended that all those in immediate contact with patients should wear gauze masks, in addition to the ordinary prophylactic procedures usually carried out in hospitals for infectious diseases, and an attempt was made to follow the recommendations. The great amount of work that was to be done, with the small number of employees available to do it, very soon showed the impracticability of this measure; and at the end of a month the order for its enforcement was rescinded. No attending physician, nurse or other employee in the hospitals developed the disease during the epidemic. 4. Physiological treatment— This treatment consisted in the intraspinal administration of adrenalin, on the hypothesis that the congested membranes of the cord could be restored to their normal physiological condition by the introduction of this substance into the spinal canal after lumbar puncture. The results obtained did not justify its use; it was not found to be superior to other forms of treatment. Simple lumbar puncture, on the other hand, often relieved the pressure, either when accompanied by symptoms or not; this measure was frequently followed by rapid and permanent improvement. 5. Serum therapy— Serum therapy of various kinds was tried. In some cases treated outside of the hospitals, and the effects of which were observed after ad- mission, diphtheria antitoxin was administered—a most unwarrantable pro- cedure. No good results were visible. Normal horse serum, intraspinally, given on the theory that some of the antibodies contained in the serum would produce beneficial effects, was tried in a series of cases and many favorable reports were made. A com- plete analysis of these cases revealed the fact that its use was not justified; nor is there any scientific reason to believe in a possible specificity of such serum in the treatment of poliomyelitis. Normal human serum from properly tested donors, i. e., healthy persons who never had poliomyelitis, was tried in a series of cases with many ap- parently striking examples of recovery; but these were paralleled by other striking recoveries in patients who received no serum. Immune human serum from persons who had recently recovered from an attack of poliomyelitis was employed in a large number of cases with some beneficial results ; but none of these gave sufficient evidence of curative effect to justify the adoption of such serum as a specific cure for the disease. 246 6. Hydro-therapy— Hydrotherapeutic measures were restricted to the use of the simple baths and enemas commonly employed in children’s diseases. Aside from the relief of pain, frequently experienced by patients from the effect of warm baths, no particularly favorable results were noted. Electro-therapy, which has been recommended by some authorities for the treatment of poliomyelitis, was not used in the hospitals of the Depart- ment. 7. Orthopedic treatment— The most important service in the treatment of cases in the hospitals was that rendered by the orthopedic surgeons in the treatment of paralysis and correction of deformities. The long period of quarantine (six to eight weeks) in the hospitals carried the patients over the stage of pain and up to the point, in many instances, of beginning contractures. By close obser- vation the orthopedic surgeons were able to determine just when to apply plaster dressings, and when to remove them to fit braces on the patients. Opportunity offered also for beginning massage of the affected muscles by the masseuses, under the immediate direction of the surgeons, who could point out to them exactly what muscles were to be massaged and which were not. In addition, it allowed the patients to become acquainted with the masseuses, so that when the after-care was continued in the homes there was no fear to be allayed on account of the unaccustomed treatment. Following is a summary of the treatments given at the Department Hospitals: F — i —— Willard Kingston Queens- Parker Avenue Riverside boro Treatments. Hospital. Hospital. Hospital, Hospital. Total. SELUIN hs iii ass aviais ssa mialavie 34 i. 3 2 39 Adremalinsl vn... ovis rin eas 2 11 23 5 36 Ouinine ......... Saimin’ 8 ir at in 8 Horse Serum ...... oe de 3 98 re 2 SoinaleRluidl ... ovis shane or ho n a 11 Immune Serum’... vevasindsnos sonics 114 a vs 2% 114 Normal ‘Blood Citrated......cvvv4s 2 i ix s 2 Anti-meningitis Serum ............ 3 ba 3 5 3 Anti-influenza Serum ............. 1 ois w= “ 1 Symptomatic... 0 sire ddnsies 1,489 563 929 102 3,083 Convalescent Serum—Spinal ...... ho 9 nn Ey, 9 Convalescent Serum—Muscular ... oh 6 3 + 6 Botal tino iid oR 2,074 1,049 1,203 190 4,516 247 The clinical reports from the four hospitals of the Department, repre- senting as they do the observations, clinical notes and conclusions of lead- ing clinicians in the four large boroughs of the city, have much value for the practicing physician. SuMMARY OF TREATMENTS AT WILLARD PARKER HOSPITAL. At Willard Parker Hospital the following data are summarized from the bedside notes and histories where immune human serum was given intraspinally during the paralytic stage of the disease in 142 cases: Duration of Illness on Age. Admission. Ca 4 75 6 months and under. 3 1day .o..cvvivnet 3 Bin i & 67 7 to: 12 months...... MM 2 days... anntet on es 1to 2 years....... 55 Jdays hres 41 142 3. 10/5" years. 5. yu, 45 4 days ovoigsh dv 16 0 to 10 years......» 21 BAYS Jiuvouvaiaes 11 Over 21 vears...... 4 6days .... vise, 8 — 7 days...) cana 10 142 Says. i veri 1 9.days .... 05 sete 1 10 days ....5. suse 1 11 days uous ennens 1 12 days ...iv. unin 1 14:days ....... 000 1 Not given... iva 20 142 The history of the number of days ill previous to admission is probably inexact in very many cases as parents in many instances dated beginning of illness from Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement [nvolvement onset of paralysis. Temperature on Admission. 08.6 10 100°. suns tr innins sate 41 100 40-1028, . «rivinni ahs 70 102 40: AOL... 0 a ins 20 Over OBE oui ain suid in dis wits I 142 Paralysis on Admission. of: one upper Bmbionly., 0.55 ei naa ake as 9 of- one: lower Hb only. 5 vias va ido oividle = vialoiatyts ute 17 of one upper and Oe IOWeET. ...css/scv wuss ves en's suis 3 of both upper limbs. vl ivi sd vealiivn wa aloft nills, 6 OE DO TOWEES J. oho 4 ravens atiiata) of is wrth sities irnatethi oe 30 Of All etree y vw. © iano n § viii it 4 se tn wie 11 Of Tacialionly i ovis von 20 eh on surmsi sin wd anaios ies ae 13 of facial and appers. vu. cease vias Fada wien sinkaian ted 11 fone upper and wo JOWersie ove tis chine ies nisins : 3 of facial, intercostal and abdominal muscle. .......... 1 Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement Involvement The serum was administered as soon as possible after admission. of of of of of of of of of of of of of of of of of of of of of one upper, one lower and intercostals............. muscles of deglutition only facial, deglutition and both lowers................ all extremities and intercostals................... all extremities and deglutition facial and deglutition both lowers and abdominal muscles. .............. one lower, two uppers and intercostals. ........... one upper and intercostals both uppers and deglutition facial, deglutition and intercostals................ diaphragm and intercostals facial and one lower eXIremily. «ove env rrnsis suns intercostals only with stupor deglutition and intercostals facial deglutition and both uppers................ facial and both lowers intercostals, both lowers and abdominal muscles. ... deglutition, intercostals and one upper............ deglutition and one upper facial, intercostals, both uppers and one lower. .... 248 des EEE LEE SEI EE t EEE w PRB sss Yrs swe vase. | —_ N= WWNNDNMF MFM DNWNDND WE WE 142 Serum Treatment. A few cases whose paralysis became progressive after admission naturally received their serum at a longer interval after admission. A few cases which resembled intercostal paralysis at onset and later proved to be broncho- pneumonia received serum several days after admission to the hospital. Serum Serum Serum Serum Serum Serum Serum Serum Serum received received received received received received received received received within within within within within within within within within 12 hours after admission. ..yvven exis 88 12 to 24 hours after admission. ..... 34 24 to 48 hours after admission. ..... 12 3 days after admission.v..isvs ons 2 4 days after admission............ 1 6 days after admission. c.oeclinneis 1 7 days after admission... iueis «sci wis %2 O' days after admission..v. ...ec in 71 21 days after admission............ 1 The types of serum used were mal horse serum. (a) poliomyelitis convalescent human serum referred to as “ Immune serum,” (b) normal human serum, (c) nor- The immune serum was taken from individuals who had recovered from poliomyelitis at intervals of a few months to several years * One Thc. Meningitis. + Broncho-pneu. One Broncho-pneu. previously. 249 The serum was taken only from those in good health. A Wassermann test was made on all specimens of human serum before they were accepted for use. Administration was intraspinal. Patients. Normal human serum was administered to................. 34 Normal horse serum was administered t0....... corre reves 3 . “Immune ” human serum was administered to.............. 93 Serum, {ype not stated, was administered to. i, oil vs sus, 12 4 patients received 8 c.c. of serum. 13 patients received 10 c.c. of serum. 121 patients received 15 c.c. of serum. 4 patients received 20 c.c. of serum. In a few cases within 3 or 4 hours after the introduction of the serum there was a sharp rise or fall in temperature. In the other cases the tem- perature remained relatively the same for 24-72 hours, but then began to fall. In the progressive cases which resulted fatally, the temperature usually continued to climb until death occurred. As a rule, after the serum, there were more or less well marked signs of meningeal irritation manifested by rise in temperature, irregular cardiac action, retraction of head, stiffness of neck and back, general hyperesthesia, increased irritability and in the more severe cases stupor or delirium. The percentage of the more marked reac- tion was relatively the same for all types of serum. Temperature dropped 1° in 9 cases. Temperature rose 1° in 25 cases. Temperature dropped 2° in 7 cases. Temperature rose 2° in 22 cases. Temperature dropped 3° in 2 cases. Temperature rose 3° in 4 cases. Temperature rose 5° in 2 cases. Temperature rose 7° in 1 case. The temperature remained relatively the same in 70 cases. A severe meningeal reaction occurred in 11 cases. A second dose of serum was given after an interval of 24 hours. First—When the general condition of patient did not seem better. Second—When the temperature still remained elevated or there was still evidence of progression of the involvement. Third—When there was no well marked signs of meningeal irritation after the first dose. Thirty-six patients received second injections of serum: 9 patients received normal human serum. 3 patients received normal horse serum. 24 patients received normal immune human serum. 1 patient received 8 c.c. of serum. 1 patient received 10 c.c. of serum. 34 patients received 15 c.c. of serum. 250 The temperature after second dose reacted as follows: Drop of 15%. aes canunsiiinme 2 cases. Risetof 42. coats rnsvanamannns vue 2 cases. Rissof2%........0..0.% Foe 2 cases. Riser ol 30... hu. eset ne Jalan 2 cases. Ris@eaf 58. 0. ss doh vasbv sites iii da 1 case. Relatively no change in 24 hours. .... 27 cases. Signs of severe meningeal irritation occurred in four cases. A third dose of serum was administered after an interval of 24 hours to two patients. Each received 15 c.c. of “immune” serum. There were no reactions. SERUM TREATMENT IN PRE-PARALYTIC CASES AT THE WILLARD PARKER HospiTAL. Clinical notes on 17 cases in whom immune serum was used in the pre-paralytic stage are summarized as follows: Age. Tdo: 2 years. iii. innrins 3 SAO IB VBArS 5 aire sw wavs an nnd 11 O30 10 years. .. Sere olor s tse nha 3 Days Ill on Admission. Liday: 2 Two cases receiving treatment before admission: 2: days: ..... 6 3 days... 3 I-22 days. i vies ovis 1 4 days....... 1 5 days....2000 000, 1 Si days... ....; 4 Otdavs....... 1 Temperature on Admission. 98.6-100..... 2 Those receiving treatment before admission: 100-102... . . . 7.798.616 102..........%1 Overi102....,- 6 Over 102.0... ove 1 Condition on Admission. Following is the physical condition as determined on admission : Weakness of both lower extremeties and rigidity of neck........... Weakness of one upper exiremity.only............... SER ery ir Tremor of an upper extremity with rigidity of neck............... Weakness of neck and Back only... oov vis er ernst inicrninsnsannns Weakness of back and Doth 1oWers. «ovo uvus vrs shins rsnsninsnss Ricidityof neckalone.. .. vidi vainiivrininns van wasas nn van Wncerinine gait only... ainsi vine Th dd stars dans ve als Rigid neck, uncertain gait and tremor of uppers.................. Semi-comatose, slightly rigid neck, flaccidity of extremities (died 32 hours after admission) NN —-—-h — 251 Two cases having had one or more treatment with immune serum prior to admission, had on admission : Weakness of neck and Dack only. co «vei svns vrnisi sss saisnntiie ts we inets 1 Signs of marked meningeal IrHitation:. vv: vs + vp vsisvismrnaisiinniisns 1 One case showed some rigidity of neck on flexion. Temperature 101 and spinal fluid of type found in poliomyelitis. .............. 1 Amount of Serum and Number of Treatments. Fifteen c.c. of serum was the usual dose. One patient received one injection. of 8 c.c. Three patients received one injection each of normal serum. Two patients received two injections each of normal serum. Ten patients received one injection each of immune serum. One patient received two injections each of immune serum. , One patient received two injections of immune serum before admission and (one when admitted.) One patient received one injection of immune serum before admission and (one when admitted.) Results of Administration of Serum. The usual immediate response following the introduction of serum was a varying degree of meningeal irritation, stiffness of neck and back in mild cases, retraction of head, rigid neck and back, marked irritability and hyper- aesthesia, Kernigs reflex present and sometimes slight stupor in the more severe cases. In this series there were five well marked reactions and three very severe ones. The temperature in five instances rose one to four and a half degrees following introduction of serum, but the usual tendency was for the tem- perature to fall, reaching normal in from 24 hours to 6 days. Fourteen cases failed to develop any farther manifestations of the pathologic process, returning to normal in a few days or weeks. Two cases went on to paralysis after the administration of the normal serum. One case admitted—three days ill on admission—temperature 102 degrees, with weakness of muscles of back and right lower extremity, developed paralysis of both lower extremities. There was a severe reaction after the serum was given. Finally, in another case, admitted with temperature 101 de- grees, which dropped to normal within four hours when normal serum was introduced there was no reaction but the patient developed paralysis of one upper extremity. One case received normal human serum. Temperature 104 degrees on admission fell to 102 degrees, then continued rising to 107 degrees at time of death. Pulse rose from 100 to 160, respirations thirty. Patient was comatose. No paralysis, but general flaccidity.. Died thirty-two hours after admission. 252 Of these 18 cases, 1 died and 2 developed paralysis. The condition of 5 cases was temporarily much worse as a result of meningeal reaction, caused by the serum. In three cases the reaction was so severe as to make the prognosis very grave for several days. Treatment With Quinine. In six cases, quinine and urea hydrochloride was used intraspinally because of its ready solubility and rapid absorption. It was administered as follows, promptly on admission of the patient: Patients under five years of age received grains ten (X) intra- muscularly, then grains three (III) per mouth three hours later and continued every three hours for the next twenty-four hours. Patients over five years of age received grains twenty (XX) intramuscularly, then grains five (V) per mouth three hours later and continued every three hours for the next twenty-four hours. The history of the six cases thus treated is as follows: Case 1. Age, two years. Ill three days on admission, tempera- ture 103°. Involvement of all four extremities, intercostal and ab- dominal muscles. Temperature rose to 106°. Patient died fourteen hours after admission. Case 2. Age, nine months. Ill two days on admission. Tem- perature, 102.6°. Involvement of all four extremities and abdominal muscles. Developed paralysis of intercostals. Temperature con- tinued rising to 105°. Died twenty-eight hours after admission. Case 3. Age, three years. Ill three days on admission. Tem- perature, 104°. Involvement of left side of face and muscles of deglutition. Developed paralysis of intercostals. Died seventeen hours after admission. Temperature fell to 103° about four hours after admission, then rose to 107° eight hours later, and was 104° at time of death. Case 4. Age, seven years. Ill five days on admission. Tem- perature, 102°. Complete paralysis of both lower extremities, weak- ness of muscles about both shoulders and of back. Temperature arose to 104° about six hours after admission, then fell to 100° at the end of the first twenty-four hours. The condition at the end of the twenty-four hours was weakness of muscles about right shoulder, paralysis of muscles about left shoulder and paralysis of both lower extremities and weakness of back muscles. Four weeks later muscles about left shoulder had practically recovered from paralysis. At the time of discharge (end of eight weeks) the paralysis in the lower extremities had not improved. Case 5. Age, three years. Ill four days on admission. Tem- perature, 102°. Weakness of muscles of left thigh and of back and neck. Phonation slurring, slightly stuporous. Twenty-four hours later temperature had fallen to about normal and remained there. There was irregularity in volume and rythm of respirations, paralysis of muscles of left thigh and was still slightly stuporous. Three days later respirations and mental condition were normal. Paralysis of left thigh cleared up in about four weeks. 253 Case 6. Age, two and one-half years. Ill one day on admission. Temperature, 101°. Slight weakness of left facial muscles and stiff- ness of neck. Gait ataxic. Six hours later temperature rose to 104°. At the end of twenty-four hours temperature was 100° and reached normal on the fifth day. Twenty-four hours after admission the patient was delirious and stuporous. Intercostal muscles apparently paralyzed. The intercostal involvement lasted three days, after which time costal breathing began to return. At time of discharge (end of eight weeks) there was no apparent paralysis or weakness. It is difficult to draw any conclusions as to the efficiency or non-efficiency of any form of specific therapy in poliomyelitis as we have seen parallel cases, one receiving a specific form of treatment and the other merely symptomatic treatment, pursue exactly similar courses. It seems fair to assume that quinine (1) does not arrest severe pro- gressive cases, (2) does not hasten the recovery from a paralysis, (3) does not absolutely prevent the onset of a paralysis when administered in the early stages, (4) may be of some benefit in the so-called pre-paralytic phase. As the cases received in this hospital had usually reached the paralytic stage this conclusion could not definitely be determined. SUMMARY OF TREATMENTS AT THE KINGSTON AVENUE HospITAL. At Kingston Avenue Hospital, as at the other Department hospitals, cases which were recognized clinically as of a mild type and with no serious or threatening symptoms, were treated symptomatically and no special methods directed at the cause of the disease process were employed. Of the 1,017 cases cared for at this hospital, through the full period of isola- tion 488 received special treatment of some kind. In 328 cases lumbar puncture was used. In 209 a single puncture to relieve severe meningitic or hydrocephalic symptoms, and in 119 multiple punctures, and of these 121 died—37 per cent. In 27 auto-inoculation intramuscularly with spinal fluid was used. Among these there were 15 deaths—(56 per cent.) In 98 horse serum was used intraspinally and intramuscularly with 35 deaths (35 per cent.). Of the 63 cases which recovered, in 22 the records of paralysis at admission and discharge were not sufficiently complete to report; in 5 cases paralysis which was present on admission had disappeared on date of discharge; in 13 paralysis had improved greatly between admis- sion and discharge ; in 12 paralysis had improved moderately between admis- sion and discharge; in 10 paralysis had improved slightly between admission and discharge; in 1 paralysis had not improved between admission and discharge. In 5 diphtheria antitoxin was used with 3 deaths. In 11 cases adrenalin was used with 9 deaths. In 19 cases immune (or convalescent) serum was used intraspinally in 11 and intramuscularly in 8 cases with 8 and 5 deaths respectively. Lumbar puncture and the various types of treatment having that as their basis were used in only the more severe types of cases. 254 As paralysis had already supervened in practically all the cases, influence of the treatment as a preventive measure was not determined. It seemed, however, that improvement of the paralysis was more rapid in cases in which lumbar punctures were performed. The relief of hydro- cephalic symptoms following puncture was marked and often complete. Best results were obtained with simple and multiple puncture and with a combination of puncture and horse serum. SUMMARY OF TREATMENTS AT RIVERSIDE HOSPITAL. At Riverside Hospital, in 259 of the 665 cases, special treatment was used. ; Lumbar puncture in 156 cases (61 toxic and 95 non-toxic) with 21 deaths (13.4 per cent.). Of these deaths, 13 were in the toxic group and 5 were in the non-toxic group. Of 81 cases treated with adrenalin intraspinally, as advised by Dr. Meltzer, 35 died, giving a death rate of 43 per cent. Sixty were toxic and 21 non-toxic. Of these 6 were non-paralytic, all of extremely toxic type and all but one dying within 48 hours of admission, the other 75-cases having paralysis of all degrees of severity and extent. Of 60 toxic cases 27 died—45 per cent. Of 21 non-toxic cases 8 died—38 per cent. Of 24 cases treated with adrenalin intramuscularly 14 died—63.6 per cent. [Eighteen were toxic, of whom 13 died—72.02 per cent. Non-toxic, 4, of which one died—25 per cent. Two were non-paralytic prostrated mori- bund cases, living only 1 and 2 days respectively, the remainder having paralysis of varying degrees. SUMMARY OF TREATMENTS AT QUEENSBORO HOSPITAL. At the Queensboro Hospital 43 cases were treated by spinal puncture, with 17 deaths—39.5 per cent. In 19 cases adrenalin was used intraspinally, with 10 deaths—>52 per cent. In 4 cases immune serum was used intra- spinally, with 2 deaths. The opinion of the visiting and resident staff was definite that in cases showing serious symptoms better results were obtained from the use of simple puncture (single or multiple) than when puncture was followed by the administration of any serum or medicament. SoME HOSPITAL STATISTICS. Following is a table showing the activities of the Department hospitals during the epidemic, the date and number of cases first admitted, the num- ber of cases discharged with and without visible paralysis, number of deaths and mortality rates, and other hospital data: 25% Willard Kingston Queens- Parker Avenue Riverside boro Hospital. Hospital. Hospital, Hospital. Total Date first case was admitted....... 6/28/16 6/20/16 6/30/16 7/18/16 Admitted :— Total admissions incl. transfers. 2,078 1,809 1211 339 5,427 Largest number in one day.... 108 64 66 14 irae Smallest number in one day.... 1 1 1 1 ed Number cases discharged.......... 1,707 826 1,064 152 3,749 Number of deaths..........c00s00. 322 244 110 40 716 Mortality wie crt oes snumanssmesss 15.8 2;.5 9.3 20.8 16.0 Duplicate transfers fo other hospitals and cases still under treatment account for the discrepancy between the total of 4,475 deaths and cases discharged, and the total admissions recorded, 5,427. Willard Kingston Queens- Parker Avenue Riverside boro Hospital. Hospital. Hospital. Hospital. Total. Largest number in hospital at ONE HME: coda: ollie ne sens 1,035 054 778 134 ree Average number of patients per QaY . . sunnins chs samreive ss van 670 461 325 60 iE sere Patient days... o.iamasiaess 78,609 46,259 48,835 8078 a vee Average days per patient....... 27.8 25.6 40.2 20. i teehee Cases admitted as poliomyelitis, discharged no case........... 42 42 92 .5.. 181— 4.9% Cases discharged with visible paralysis uo. iv. asninsnisan ie 1,065 684 665 112 °° 2,526—67.4% Cases discharged with no paraly- . . SESE" 2s sinned e rs vitibant or2 3 Fetes 642 142 399 40 1,223—-32.6% The largest number of employees at one time in the hospitals during the epidemic was 1,431, including doctors 83, and nurses 585. There were 9,606 visits made by parents to their children, and 2,008 visits made by private physicians to patients in whom they were interested. Of 1,707 cases cared for continuously in the Willard Parker Hospital, 322 died, or 15.8 per cent. Of 1,064 cases cared for continuously in the Riverside Hospital, 110 died, or 9.3 per cent. Of 826 cases cared for contintously in the Kingston Ann Hospital, 244 died, or 27.8 per cent. Of 152 cases cared for continuously in the Ctsoniniindo Hospital, 40 died, or 20.8 per cent. The higher mortality in the Kingston Avenue al Queensboro Hospitals is to be explained by the fact that the acute cases progressing toward recov- ery were frequently transferred to the Willard Parker and Riverside Hos- pitals, while the severe cases, which were too ill to move, or which died 256 shortly after admission, were retained in the hospital where they were first admitted. Condition of Patient on Discharge From Department Hospitals. List of poliomyelitis cases discharged with paralysis (partial and com- plete) from the Department Hospitals: Willard Parker Hospital (1,065 cases) : Involvement of lower extremities only.........coceviivnn.nn. 529 Involvement of upper extremities only.............covvinnnn 104 Cavolvement of head and neck... vei vionivis sans vans sas 122 Involvement of lower and upper extremities. .......coveveen.. 111 Involvement of back and lower extremities...........ceunen.. 139 Involvement of back and upper extremities.................. 12 Involvement of face with upper extremities.............v.... 7 Involvement of face with lower extremities...........v...... 19 Involvement of hack: only... «ou vovvis cvnion mn sen va danas viv 20 Kingston Avenue Hospital (638 cases) : Paralysis (partial and complete) of group of muscles and special cases: RCE, rd EL i a esl Jn ale atu we be Noe toh aha see te mn Ak 102 IN OC re ot i rsida btu th rs ot ARR 4 Ta oH Tee aC ee eel ALi 319 Back a an Ra sr ery CE hha ep ae mae eee 365 RESDITAOIY is o/s sce eins Ans pd aniniuie'ns x win m hon Suni d idbn WAH us Foi 108 (Intercostal and Diaphragm) Both upper eXirenibies. «vu «sis snr + inne nt Bintan in cin wy aims Zc 01 Both lower extremities... vat snst sr amasrnrnnanuesasss ss 358 Richi upper extremities. ii rues ovr Soule stats nto tnoiiin ats 41 Right dower extrentiiies. . . iv vos civ siv's 4 sews nnernehnsssvisions 45 Left upper extremities. ....c. viva. rs me ne hele 49 Leltlower extremities. vu vc soir vo ms ns din se sins inlein ae asin siei's 52 SIrADIBMUS i iiss cena mis infos bee ae a ae ra 15 TL NN SL NN he iE ER RT ND) 6 PIOBIS iis rs vee SRO a is ot onal oa a An 4 Roe i AREA £5 Br th 3 Bet a hr th dies mine dell de Ste bose So i at at ve 11 BSODHASEAL cites vive so wich s Bastin nies 699 2 000 waiai's sown sis 20 ATHCIIAHION vsti Ver tenes # nntns wins 5 nse sltan aries doit m8 aan 4 APDNOIIT in bs irs rvssi tion shatsstin s Wns os ASasviak he wivciinis Jos 6 ALTE ool oi cain vi oath rt ate ae itera BE AEE 35 257 Riverside Hospital (665 cases) : BRC inion nnn sis shinins es ulti sin nm tna ninis sal nin sim isleini a bie ais vin tan Pace and trite. sia eiisis sin nag sins wv sats ndiniale nals nin'din/s ents Face and FICRelS. so aii do deimvinh dun vinta sono aih and sthass aieialeniefels Lower extremity and rickets........... coccinea. Lower extremity and upper left extremity................... Lower right extremity. .coovsvusvrerancrsrnientricecrrrnns Lower extremity and upper right extremity.................. Lower extremity, neck and trunk.............ccooiivennnn.t Lower extremity, trunk and rickets..............ovvvvnunnnn Lower right extremity and rickets...............c.cvvvinttn. Lower and upper left exiremities............cccevvensrrrnn Lower extremity and upper trunk...covvuvvnaveniaasiisees Lower left and upper right extremities. .......c..0cc0ussress Tower Tight exIreIty st se ve mas a iwivlaaios aii a loin sincels srl Lower left extremity and rickets... .. 0. hiss vile sis saisailes Lower extremity and trunk. 0. iol cal sees se die Lower left extremity, trunk and rickets... ove can dav ausleh ll Lower extremity, shoulder and neck.........eevvuuunnntnines Lower left extremity and tronk.. cnn. ni vin sho selene Lower right extremity and trunk...) avai silva si sin tines Lower extremity and rickefs, uv oes vaiens suisisiihs sis sintois site Lower extremity and ace... iva cuisines rs snsiveisisinks sutriells Lower left extremity and right, neck and trunk............... Lower left and right, upper left and right extremities......... Lower and upper right extremities. ve scan sos sisi pinioall Lower: left extremity and face... ol irae dali nisin seen tii, Tower extremity and drunk. vars dle dione s sini vn sit ee ais pita Lower left and right extremities and face. .... oi onioci sionals Lower left: extremly, « vo o's oiuniel nu idets sitio mais din mies ste Cie tte Y.ower left and right extremities and rickets.................. Yower left extremity and NECK o/c cn ees vs sasisivs sisins a ts niainie Lower lefo extremity and trank. cio ois 0s aii vr wbianie mainierels Lower, and upper left exiremities and trumk...... coievs sin ies Lower left and right and upper right extremities............. Lower and upper left extremities and neck... o.oo vs ens vin sis Y.ower extremity and shotlder... ue ii ius dia nirvs sin Lower extremity and face... rian via vil os nidiaeisin s'eiwniale Lower right extremity ‘and ricktels. wos. .cievesiaiaiinnesoms Lower'left extremity and ricketss....... cu. odie Guiseley Y.ower right extremity and £8Ce. .. coc sivas ssvns msine rs onins Lower right and upper left extremities and shoulder........... Lower left extremity, ‘face and Trunk... .. cova rsssinnos ve vinin nN O nN it HNO WUnO =H NnNO WPA NOVO® pt — — Po ft ft ANNA LWNWN NNR O WRN WHA OD — 258 Riverside Hospital: — w Lower rightiextremity anditrunke.. co. is nie vats modi s vias Lower and upper left extremities and face................... 5 Lower left extremity and face. ui cos ves dann vanes sons vos 4 Lower left and right extremities and rickets. ..... 5. sa sis avais 5 Lower left and upper right eXIremities. . .v vis ver vs wrist vis ase 36 J OWer CRITEMILY Gs vis a0 hoa is Tbe sala ess SEsEs eis 24 Neck and Cranks rr oon ve iahisie dns sri eidsis is sairie siasiynlaiis 6 i EE A Ee ne Ch 10 Necle face and trl... oon coe iiss oe oh vats tn vin mila hs tininn 4 Neck anditrunk. coor oi iE ey res ie Ti tite berms 1 RuCKEIS io 0 fini usa in dina gitiets vis 4 FS east a5 ots B wl Side 14 HT RA an Rm LE Co by ia NR eter lal eg TE hl 23 Drunk and rickels. . opie saving co snip eed sion disie 3s aint 2 Trunk, £306 and TiCKetS cil oir con vin sn ini nis re vin xsl shins win he 4 Dipperileft extremily cvcoii rr ssininn on « a inina fences al © Sh ar eintnis's 10 I pper right extremity. 6. ha iihis Shs le Ba he tine Bare maracas 9 Io pperiestiretity (1. yore Fons leis Jonata ha sie aE 45 Upper and 1oWer extremities. ov. cos voile as uals wba sit bors wis 12 Upper extremity and Fa0e, 0 +7 ses Joiuinsiniin maw £ iain id Kon 8 Upper extremity and £808. ov. civ sine vu ove into sams ianles ie valils 2 Upper left and right extremities and face......... ccvvvnen.. 1 Upper left and right extremities... ..... 0 bss snsninsas sins 8 Upper right extremity and trunk. .... ..00 vue sas vsbisin sos » 2 Upper left and right extremities, lower left and right extremities HE Er A ee IPR R ARE NNSA SS SE CLO 7 Wpperiright extremity and £808.50 01003 7% sits sih hve ina sos iia as 3 Upper and lower extremities and rickets. i... cv oui venins vans 3 Upper and lower extremities, trunk and rickets. ...... dea 4 Upper and lower extremities, trunk and face................. 9 Upper left exiremity and trtnk. cv ou Js calls iala sisi sis aisle din sin ain 6 Der TIN CRTC ss visi iso nv vv vied Ente mn wsliatia ita 4751 an 9 Epper right extremity andi face. 0. 1. 43. Sorina ous iai vans 13 For further details and charts on individual special cases, many of which are of great clinical interest, reference must be made direct to the histories of cases, which will be made accessible to physicians at the hos- pitals on request. Visitors TO ‘OBSERVE TREATMENT. In addition to a number of prominent executives from other cities and states, as well as the Governor of Mississippi, Sir Henry Burdett of London, England, and Dr. Kuyea of Tokio University, Japan, physicians and health officers, to the number of 821, visited the hospitals of the Department of 259 Health for the purpose of studying the diagnosis and treatment of the dis- ease. The following list is copied from the visitors’ books at the hospitals: Foreign Countries: CUDA oe Sarl re nanbntd 6 Halt ns dies say dan is) 1 Ching as svs visi wlan has 1 NVahicouver uu. nid. adie. 1 United States: Connecticth ou ia: wuts onins 13 Montana...» a ies 3 California cu sus wink va wis 5 Nebraska. ...ii. coi sme 1 Delaware woh. vs vik Peis 3 North Carolina c.... vids os 12 Florida ash crea he 7 North Dakota i... ... 00. 3 GEIR ona Warm nite in # 3 New Jersey ...u.. ines... 24 Tinole et i a bine 10 New York oa 604 Towa did Sr aL 2 OYegOn vi) kl os sul os 1 Indiana. lh Rs Steen 4 Oldahoma lo. cei 3 Wentucky .. Lat an, 2 Ohior-% caine LL 18 Massachusetts ............ 5 Pennsylvanial.. . ...0 LL, 8 Michigan, du wine. Suu, 5 South Carolina... 2000 15 MInBesotd arly « ote watniic ns 12 Texas Lai aaa 8 NASSOULL T1545 sta venir at bent wie i'w 2 Tennessee... 0h 0 ee) 11 DISSISBIPDE we Bh pesiiabe leis fis 4 Vermont... «ios 3 Maryland ©... abhi bh ates 6 West Virginia ............ 6 MAE isis sas vs sassamaisas 3 Washington, D. 'C......... 6 NEWSPAPER REPRESENTATIVES VISIT DEPARTMENT HOSPITALS. With the removal of hundreds of children ill with poliomyelitis to the hospitals of the Department of Health, public interest naturally centered in the conditions obtaining at these hospitals. In order to forestall the de- velopment of any prejudice on the part of the public to the extensive hos- pitalization of cases of poliomyelitis contemplated by the Department of Health an invitation was extended to the newspaper representatives to visit any of the Department’s hospitals, see the conditions there prevailing, and report fully on the result of their inspection. For a similar reason facilities were extended to the representatives of several newspapers to study the work of the inspectors and nurses in the field, and particularly the work ot the ambulances removing patients to the hospital. These invitations were .accepted and resulted in the publication of full descriptions of the care given to the patients by the Department of Health. This frank attitude on the part of the Department of Health served to inspire public confidence and rendered the work of the Department less difficult than it otherwise would have been. Hospirarization 1x OtaER CITY INsTITUTIONS. Early in July it became apparent that the epidemic of poliomyelitis was progressing at such a rate that the facilities in the hospitals of the De- 260 partment of Health would be insufficient to care for all cases requiring hospitalization. As many as sixty to one hundred and ten new cases were reported daily, and from fifty to sixty per cent. of these had to be removed for treatment to the hospitals of the Department. A plan was outlined to secure the services of private hospitals through- out the city. : It was decided that the hospitals of the Department of Public Charities and Bellevue and Allied Hospitals, as well as private hospitals throughout the city, be invited to co-operate with the Department of Health; and on July 8th the Commissioner of Health addressed a letter to the superintend- ents of most of the large private hospitals asking if the hospitals under their jurisdiction would accept cases of poliomyelitis. The cost of caring for these patients would be borne by the city, and the charges were to be made upon certification by the Department of Health through the Department of Finance on the special emergency funds author- ized to enable the Department of Health to cope with the epidemic. The rate, per case per day, allowed by the Comptroller, was $1.25. This rate had been the standard established according to the budget of the city for cases assigned by the Department of Public Charities to institutions, and in estimating the service rendered to the community by the private hospitals, it should be appreciated that this rate did not fully compensate the hospitals for the care given to the patients. The same rules enforced in the hospitals of the Department of Health were imposed as a condition on the private hospitals in caring for such cases. A daily record was kept of new cases reported, assignments to all hos- pitals, transfers from all hospitals, number of cases, and available vacancies in all hospitals. July 12th was the first day on which this work was undertaken, and on that day 17 cases were sent to 11 private hospitals and 22 cases to the hospitals of the Department of Public Charities and Bellevue and Allied Hospitals. In order to avoid difficulties, cases had to be admitted gradually so that on an average of one hundred new cases were removed to these private hospitals each week. The highest number of cases admitted in any one day was recorded on August 28th, when the census of the private hospitals showed 726 cases. The hospitals of the Department of Public Charities and Bellevue and Allied Hospitals began with a census of 22 cases. This was increased to 660 cases on August 20th. The hospital on Swinburne Island, under the jurisdiction of the Health Officer of the Port of New York, came to the assistance of the Department in the earlier stages of the epidemic. This hospital has a capacity of only 75 beds, and whenever the cases reached that figure, twenty to twenty-five of the oldest cases were transferred to a hospital of the Department of Health so as to make room for new cases only from the Borough of Richmond throughout the epidemic. 261 During the epidemic an effort was made to send children to the hos- pitals within their home borough, and as far as possible nearest to their residence. This was done not only for the convenience of parents in visit- ing their children, but to reduce the danger in transporting children by ambulances from their homes to the hospitals. The twenty-eight hospitals that accepted the invitation of the Com- missioner of Health are listed in the following table: PRIVATE HOSPITALS. Borough of Manhattan. N. Y. Throat, Nose and Lung Hos- pital Babies’ Hospital Presbyterian Hospital St. Vincent's Hospital N. Y. Orthopedic Dispensary and Hospital Mt. Sinai Hospital Neurological Institute N. Y. Hospital (59th St. Branch) Flower Hospital Borough of The Bronx. Lincoln Hospital Lebanon Hospital Montefiore Home St. Francis Hospital Borough of Brooklyn. The Long Island College Hospital Methodist Episcopal Hospital St. Peter’s Hospital St. Mary’s Hospital St. Catherine’s Hospital German Hospital Borough of Queens. St. John’s Hospital Borough of Richmond. St. Vincent's Hospital of the Bor- ough of Richmond Staten Island Hospital PUBLIC HOSPITALS. Borough of Manhattan. City Hospital Metropolitan Hospital Bellevue Hospital Borough of Brooklyn. Greenpoint Hospital Kings County Hospital Borough of Richmond. Swinburne Island Hospital Tre HospiTAL SiTUuATION MONTH BY MONTH. During the month of July, of a total of 3,409 patient-days, service given for poliomyelitis patients in 20 to 27 hospitals of the city: 2,407 were in 4 Health Department Hospitals. ............ 70% 308 were in other city hospitals 577 were in private hospitals 30% 117 were in Swinburne Island Hospital | During the month of August, of a total of 16,318 patient-days in 28 to 32 hospitals: 10,591 were in Health Department Hospitals. ............. 2,450 were in other city hospitals 2,940 were in private hospitals te ee tesserae 337 were in Swinburne Island Hospital 262 During the month of September, of a total of 12,476 patient-days in 14 to 32 hospitals: 8,588 were in Health Department Hospitals.............. 70% 2,020 were in other city hospitals 1,712 were in private hospitals 156 were in Swinburne Island Hospital is Sh 30% During the month of October, of a total of 4,753 patient-days in 12 to 17 hospitals: 3,972 were in Health Department Hospitals.............. 80% 540 were in other city hospitals 20% 241 were in private hospitals ~~ { “°° "CCC After September 15th, arrangements were made with the private hos- pitals, hospitals of the Department of Public Charities, Bellevue and Allied Hospitals and the hospital on Swinburne Island to transfer all cases to the hospitals of the Department of Health where the census of poliomyelitis had been decreasing for a week or more. By October 15th these transfers were completed. . The weekly removals of cases to all hospitals were as follows: July 12-0800 ovis a wl a 447 cases, a daily average of 63 Wedypl0=28: ls eis sane a boi wie a 557 cases, a daily average of 79 July 26-30 0. =. Fs ee 693 cases, a daily average of 99 AE en es eh 778 cases, a daily average of 111 AUS ROIS. on a 710 cases, a daily average of 101 ANS 1622... lh ae be 4 560 cases, a daily average of 80 Aug 23-20. 5. ve oa LE aE 417 cases, a daily average of 59 AUG. 30-Sept. 5B. oui ih sas devivir ality sins 256 cases, a daily average of 36 Sept: 6-12... 1 A BS a 199 cases, a daily average of 28 Sept I-19, co. ede a ae 135 cases, a daily average of 19 SEPL. 20320. «vii en as a aieTera 98 cases, a daily average of 14 Sept 2T- Oct: Ji oii vin nian 75 cases, a daily average of 10 Oct d-10. ...0.... or ey a 54 cases, a daily average of 8 Oct-17 5. 00 oi a a eR RL 27 cases, a daily average of 4 Oct 28:30 ini ny Sai ee 18 cases, a daily average of 2 SUMMARY. No of Patient Month. Patients. Days. Cost. JE a Te vt pw iihesde fore dd is 4 67 $83 75 ai 524 5.763 7.153 75 GT A EG I eT 851 18,841 23,345 10 DEPLEMBEE | i, ivi ics dinsnin sis ininin on rise ron wv kk renin 676 12,561 14,117 52 Qetpberit. ol een 70 398 497 00 (001A) os aluiinlon tie fis site els Brinson sh anv ass 2,125 37.630 $45,197 12 263 The following table shows the number of cases admitted to private hospitals when the hospitals of the Department of Health were overcrowded, and the cases admitted to Department and City hospitals: Trans- Date Total ferred to First Case Cases Total Department Admitted. Admitted. Deaths. Hospitals. Department Hospitals— Willatd Parker 55 onihamee it vy silent June 28 2,077 3522 A Kitigston "AVENUE vi. its 14.ihas veil oe June 20 1,795 241 . RVers ou... viv iv sadn s vis bs rdw te June 30 1,206 110 A OUEENSDOTE S... «ivi isd ali abenin $s bens July 18 347 43 oe City Hospitals— 5,425 716 GIEENPOINE ood vi shit on +» Sninrntinis 5 vie Shue July 11 43 2 oy RENE Te ARM SNCS July 22 64 9 oh Kings. County iii wns Slims A de July: 12 103 12 as Metropolitan, ou vit fs su suid ne ss thie July 19 419 100 i Bellew ui. cnn ivicwnvantiniss fs osinne June 21 202 43 Fo Private Hospitals— 831 166 . Long Island College Hospital......... July 18 73 16 4 N. Y. Nose and Lung Hospital........ July 13 77 18 oi Lincoln Hospital and Home. .......... July 12 265 58 35 Bables" HH aspilal o.oo iin dds thd sn June 25 33 6 .. Le hanOn To das sit, Ste ie Rasa eds July 11 16 1 3 Methodist Episcopal i. cs drsnsianis sa July 18 5 1 i Presbyterian vo... iovvene int inns July 10 16 2 2 StF rancish nf mans Bh ee July 13 69 13 20 St. Vincent's (Manhattan)... visi July 10 29 3 oe N. Y. Orthopedic Dispensary.......... July 14 50 8 oe ML. Sinai iris iashnmste vod oncom June 17 58 11 13 St. Vincent's (Richmond)... iv uss July 27 9 3 te The Neurological Institute............ July 24 11 2 he StIMary'sh, eh Sa ee on he July 16 14 4 fee Staten Island Hospital... oni. on July 27 13 1 aie St. Johns ot de Ye sie July 16 12 1 ~ St. Catherine's «tain shoals vis vn su June 8 51 9 4 N. Y. Hospital (59th Street Branch)... July 12 51 8 i Baers re iin s on atitaee ole Arik Aug. 8 41 6 32 German (Brooklyn) '.... c.oviviis ess Aug. 23 14 va Ja Montefiore Home ....o.s.cniivinsnins Aug 22 11 4 Swinburne Island... 50 eed sre July 12 139 20 30 Lonise Minturn fda Seedy ud le. Aug. 16 75 4 Herlsimer Sanitarium oe. 5ok.. niia Aug. 12 12 vo i, SD RterE or, ie ihe id sas es Dl ae ih July 14 61 6 1 1,201 203 146 True and False Cases Admitted to Private Hospitals. Of 1,809 cases admitted to 28 hospitals in the city, excluding Depart- ment of Health hospitals, 1,780 were designated as true cases of polio- myelitis, and 29 as false (or 1.5 per cent.) ; 318 died, giving a mortality of 17.5 per cent; 278 cases were transferred to one of the Department of Health hospitals during convalescence to make room for additional acute cases. The unusually small number of cases designated as “ false” is worthy of special comment, as showing the accuracy of diagnosis attained by the diagnostic staff, under exceptional and trying circumstances. CHAPTER XII. A Discussion of Treatment. 1. SpecIAL STUDY OF SERUM TREATMENT. In the treatment of the acute stages of poliomyelitis, the application of immune serum from human beings who have recovered from this disease has been recommended by Netter(!), who used such serum in a small series of cases. Netter’s therapeutic use of the serum was suggested by the earlier work of Romer and Joseph(2), Landsteiner and Levaditi(®), and Flexner and Lewis(*), who detected neutralizing immune substances in the serum of monkeys that had recovered from an attack of poliomyelitis; and by the later work of Levaditi and Netter (%), and Flexner and Lewis(%), who independently showed similar immune substances in the serum of convalescent human cases; also by the subsequent work of Flexner and Lewis(7), who showed that the immune human serum had the power of preventing the development of the disease in monkeys, when injected twenty- four hours after the intracerebral inocculation of a fatal dose of virus. On the basis of these results the work with immune serum was taken up at the Willard Parker Hospital, at the Minturn Hospital and in the private practice of a number of physicians, to whom the serum was supplied for treatment of suitable cases. It was soon realized that the cases in the pre-paralytic stage of the disease would be the most suitable for serum treat- ment, and that late cases, with well developed paralysis and normal tem- peratures, would probably not be influenced by the administration of serum. The serum was also used, however, in cases where the temperature was still high, the paralysis had developed in some parts and was progressively in- volving other members of the body. It is in the group of early cases, however, treated in the premonitory or pre-paralytic stage of the disease, where we can obtain very much more 1. Netter, A.: Serotherapie de la poliomyelite nos resultats chez trente-deux malades : indications, technique, incidentes possibles, Bull. de I’Acad. de Med., Oct. 12, 1915. Deven A., and Salanier, M.: Bull. et Mem. Soc. Med. d. Hép. de Paris, March 10, 1916. 2. Romer, P. H., and Joseph, K.: Miinchen Med. Wchnschr., 1910, LVII, 568. 3. Levaditi and Landsteiner: Compt. Rend. Soc. de Biol., 1910, LX VIII, 311. 4. Flexner, Simon, and Lewis, P. A.: Experimental Poliomyelitis in Monkeys, Seventh Note, The Journal A. M. A., May 28, 1910, p. 1780. 5. Levaditi and Netter: Presse Med., 1910, XVIII, 268. 6. Flexner, Simon, and Lewis, P. A.: Seventh Note (footnote 2). 7. Flexner, Simon, and Lewis, P. A.: Experimental Poliomyelitis in Monkeys, Eighth Note, The Journal A. M. A,, Aug. 20, 1910, p. 662. 265 tangible results. If paralysis develops after the use of serum, the following points should be noted : 1. The number of doses and amount of serum used each time. 2. The group to which the serum belonged. 3. The number of days the patient has been ill. 4. The number of hours or days which have elapsed since the first dose of serum was given. 5. The degree of paralysis. 6. The rapidity with which the paralytic phenomena begin to clear up. : ; : 7. The final result; recovery, paresis or paralysis, stating the actual groups of muscles affected. It is only by comparing a large group of early cases treated with immune serum, with normal human serum, and with no serum at all, that we shall be able to arrive at any certain data as to the efficiency of the serum treatment. To help in the diagnosis of early cases the symptoms and findings in the spinal fluid are of value. The macroscopic changes in the spinal fluid, already described, cannot replace the more careful laboratory examinations, but are found to be of great service clinically, especially where immediate facilities are not at hand, and the diagnosis of poliomyelitis has to be con- firmed for purposes of isolation and treatment. Having established the diagnosis in the early cases by clinical symptoms and examination of the spinal fluid, the next step is to inject the serum into the spinal canal. It is here that the bedside confirmation of the diagnosis by the macroscopic appearance of the spinal fluid becomes most important. Where the spinal fluid indicates the presence of the disease on macroscopic or microscopic observation the serum can be promptly administered without any further delay for laboratory examination and without the necessity of another lumbar puncture, although the confirmatory laboratory examination should be made later. Fifteen c.c. of the serum is injected by the gravity method after the removal of a slightly larger amount of spinal fluid. The dose is repeated every 20-24 hours until two, or possibly three, injections have been made. In the more severe cases, especially with an advancing involvement of the respiratory muscles, the serum has been given every 12 hours. In consider- ing the frequency of the repetition of the dose, and especially of the interval of time between the injections, it is important to remember what is taking place in the cerebro-spinal meninges after an injection of the serum. A marked polynuclear cellular reaction is produced, which probably should be given time to exert its full effect before the spinal canal is tapped again and the rich cellular fluid removed, for the administration of a second or third dose of serum. If the reinjection of the serum is delayed, however, 48 hours or longer, there will be noticed a rapid clearing up of the arti- ficially produced cellular increase in the spinal fluid. Considering this therapy as a possible non-specific cellular stimulation obtained by the injec- 266 tion of a rich protein fluid, we would consider that an interval of 20-24 hours between the injections is best, but it is fair to state that in three severe cases the readministration of the serum was made every 12 hours with apparently good results. The serum is rapidly absorbed from the spinal canal, so that one daily repetition of the dose is indicated, especially if the efficiency of the serum is considered as being based in part upon its antibody content. Source of Serum—Groups of immune serum. The immune serum used in the treatment of cases of poliomyelitis was obtained from convalescents and from donors, who had had the disease from one to several years previously. For the sake of accuracy, and to facilitate the proper study of its action, the serum has been classified into groups, according to the months or years which have elapsed since the im- mune donors had the disease. It is important in choosing donors for im- mune serum to establish the fact that they had really suffered from infantile paralysis, and not to accept the diagnosis of the donor on his word, as cases of Bell's palsy, tuberculous disease of the bones and joints, hemiplegias, syphilitic and otherwise, will frequently be found among so-called “immune donors.” The groups into which the serum has been divided are as follows: Early convalescent serum......... from 2 to 6 months after an attack Late convalescent servom. ....... vu» from 6 to 12 months after an attack GrOUpIA SCIUM. .s -ivisis bain 44 from 1 to 5 years after an attack Group Biserum. ....h. ii oniis sinus from .5 to 15 years after an attack Group C ise. lan vs vn van va from 15 to 30 years after an attack Group DD Serum... i... vie sia iiss from 30 years up after an attack Method of Obtaining and Preparing the Serum— (a) Amount. To obtain the immune serum the blood is drawn from suitable donors in quantities varying with the age, weight and apparent hemoglobin content of the individual. On an average, it is safe to withdraw 2 oz. from children 9 to 10 years of age, 3 to 4 oz. from children 12 ta 13 years of age, 4 to 6 oz. from individuals 18 years of age and over. Adults, especially robust, full-blooded persons, can furnish 10 to 16 oz. of blood. Similar amounts of blood can be safely avithdrawn again at the end of two to three weeks. (b) Technique of Obtaining the Blood. The blood is obtained either by means of a No. 15 gauge steel or platinum needle, to which a small piece of rubber tubing is attached. In children, adults and stout individuals with small or indistinct veins, the blood is withdrawn by means of a 1-o0z. Record Syringe and a No. 17 gauge needle. The blood is collected in small square bottles in quantities of 1 to 2 oz., and given a long slant so as to obtain as broad a surface for the separation of the serum as is possible. (¢) Preparation of the Serum. The blood is allowed to clot, and the bottles are then placed in the ice-box during the following 267 twenty-four hours to allow a separation of the serum. This is de- canted the following day and centrifuged to free it from pieces of blood clot and red blood cells. To the serum is next added a pre- servative in the form of 0.2 per cent. trikresol.* This is added in a 25 per cent. solution in quantities of 4 c.c. to every 500 c.c. of serum. The serum is then allowed to remain in the ice-box for forty-eight hours, so that a fine precipitate, which forms after the addition of the trikresol, separates out and is removed. The serum is then passed through a Berkefeld stone filter, either by suction or pressure, bottled in quantities of 15 c.c. in dark amber or blue bottles, and kept cold in the ice-box. (d) Duration of Efficiency of the Serum. If the serum has been preserved with trikresol, or handled with sterile precautions after it has been passed through the Berkefeld filter, and is afterward kept in a cold place, it will probably remain efficient in its specific content for a number of weeks. The serum obtained was used up almost as fast as it was obtained. Some of the serum which was kept for four to six weeks seemed to be as active, therapeutically, as the more recently drawn serum. k In an emergency, or where the facilities for treating the serum are not obtainable, the blood is simply drawn under aseptic conditions in a vessel with glass beads and shaken and centrifuged ; or the serum, drawn in the usual way, is allowed to separate during the next few hours, and promptly used, disregarding entirely the presence of the few suspended red blood cells. If a further experience justifies our opinion that immune serum is beneficial, it will probably be found that the results are due partly to specific immune serum and partly to normal human serum as such. If this con- clusion proves to be true, when specific immune serum is not obtainable, it will be advisable to use normal human serum, when possible, which can easily be obtained from parents or relatives of the patient. It is important to note that in the preparation of serum, either for stock, or fresh without a preservative, no heat is applied either for inac- tivation or for sterilization. Each donor should be otherwise healthy and give a negative Wasser- mann reaction. ~ Results of Serum Treatment. The most evident action of the serum fs a marked cellular response of the cerebro-spinal meninges in the presence of the serum injected by lumbar puncture. This cellular reaction consists of a very decided increase of the polynuclear cells, which preponderate in some of the cases to the extent of 95 per cent., while the total cell count increases from 500 to 10,000 per cubic centimeter. This increase of cells is at times so pro- nounced that the spinal fluid obtained at the end of 24 hours has a very marked turbid, almost purulent appearance and a heavy sediment of cells * The trikresol increases the local irritant action of the serum, and it may be found advisable not to add it as a preservative. 268 is found in the test tube within a few hours after the lumbar puncture. Culturally, these fluids are always sterile. This cellular response is found also after the injection of normal human serum, of normal horse serum and of the secondary albumoses of Jobling, when these sera are used in the same early stages of disease. This high reactivity of the cerebro-spinal meninges is probably due to the very marked congestion of the vessels of the pia-arachnoid, and of the cerebral cortex. It is probable that in the use of immune serum we have, in addition, the assistance of antibodies against the virus of poliomyelitis, which stimulate the polynuclear cells to increased phagocytic activity. We cannot estimate the phagocytic action of the cells, as the virus is too minute to be seen. It must not be overlooked, however, that we have probably obtained therapeutic results as good after the use of serum from Group C or Group D as from Group A or B. Such sera may have only a problematic value as antisera, and almost their entire action may depend on the rich protein content of all blood sera. Further experi- mental work will, no doubt, have to be carried out in monkeys to determine whether the injection of immune sera into the spinal canal of monkeys will have a greater protective value against a previous infection with active virus than the injection of normal human sera. If the injections of immune or normal human sera are made in the later stages of the disease, when the temperature has already subsided, the cellu- lar response will be found much poorer, and only an opalescence of the spinal fluid will be noticeable at the end of 24 hours. This lessened cellular response is probably due to a subsidence of the acute congestion of the brain and meninges. Clinically, the injection of immune and of normal human serum is fol- lowed, within 24 hours in the early pre-paralytic cases, by an intensification of the meningeal symptoms. Increased rigidity of the neck, opisthotonos, marked Kernig, hyper-irritability, headache, vomiting and increased tem- perature, which reaches in the most severe reactions up to 104 or 105° F (See chart I, page 269.) At times where the reaction is especially severe we have twitchings or even convulsive movements of the extremities. These symptoms represent merely a more severe degree of the early pre-paralytic phenomena of the disease. In some of these cases the temperature is simply caught in its upward rise and, therefore, it has no significance. Definite temperature reactions have, however, been noted after the primary and also after secondary injections of serum. The typical curve can be seen from the following chart: A rise in temperature, persistence for another 24 hours, without any further increase after a second dose of serum and subsidence by a rapid lysis. (See chart II, page 271.) The other symptoms, the rigidity of the neck and Kernig persist for two-three days after the temperature has dropped to normal. Gradually the symptoms clear up and the patient, if there is no complicating paralysis, makes a rapid and uneventful convalescence. TEMPERATURE CHART I. rs J 5° Two temperature curves in cases of poliomyelitis that received immune serum. Figures at top of chart indicate duration of disease since day of onset. ' ~ ‘ \ % : : By sty = * t “1 ¢ ‘ . } » ‘ 7 { . ) . : ' s 4 - 3 . i . . = :] i . » 1 4 an ad 273 The cases treated with immune serum may be divided into three groups: 1. Cases treated at the Willard Parker Hospital. 2. Cases treated at the Minturn Hospital. 3. Cases treated with other physicians. 1. Willard Parker cases— A—Immune serum cases: (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-paralytic Cases—25 Cases. Type of Serum. Number of Doses. A lien aes iin ve One cieoeinels soiben 20 Bema 1 TWO ius Banal 4 Cle ten snide s 2s 17 Three vob iiss. 1 D .iirsvnicedelnes 7 = T= v.25 25 REsuLTs. (1) Remained free from paralysis.............. 24 (2) Weakness of both quadriceps extensors. .... i {3) Died nol dinin rin vivir ms sn ded vasa 23 (b) Paralytic Cases—88 Cases. (1) Ded odes goin oi danas is hala ies 38 (2) Lived. 5 bs snide ah a te bat as 50 Of the 38 who died: 18 died in less than 24 hours after first dose of serum, 9 died within 48 hours after first dose of serum, 5 died in more than 48 hours after the first dose of serum, 2 died of tubercular meningitis, 1 died of gastro-enteritis, 3 died of pneumonia. Type of Serum. No. of Doses. Type of Case. Convalescent cc... 1 ONE a svabteniniits + 23 Bulbar vives 7 A Nasa 4 Two i... i arnt 13 Bulbo-spinal ...... 6 Bi. te na, 10 Three: ..ovidivoein 2 Spinal: |... an leh 2 Cs i a ee 23 — Cerebral... cond 1 = 38 *Tuberculous ...... 2 38 — 38 * Found to be tuberculous on autopsy. A large proportion of the fatal cases were children in the last stages of an advancing Landry type of poliomyelitis. Of the 18 that died within less than 24 hours, a majority were moribund cases and died within a few hours after the administration of a single dose of serum. Many of the 274 patients in this group received the serum only as a last resort. The bulbar cases had well-pronounced respiratory difficulty before the serum was injected. : There were 50 who lived. Type of Serum. No. of Doses. Type of Case. Convalescent ...... 1 ONE ie rll sation las + + 39 Bulbar . coe. 8 Aiea 6 DWO. sei dalonvici ros 9 Bulbo-Spinal ...... 2 Biases 21 Three... less oes 1 Spinal ulL oar sainain 40 Clann ies 20 Four ous tives sav 1 Cerebral... .cuvse i Di... sa 2 ee a — 50 50 50 These cases already had a well-developed paralysis when treated, but were in a still active stage of the disease, as shown by temperature and a spreading type of lesion. These children recovered and showed a definite clinical improvement. It is impossible to determine how much of the im- provement, which is also generally seen in the untreated cases, was due to the administration of the serum and how much would have taken place dur- ing the natural course of the disease. B—Normal serum cases. To determine whether a similar cellular reaction would be produced by the intraspinous injection of normal serum and whether similar thera- peutic results could be obtained, a series of pre-paralytic and paralytic cases was treated with serum obtained from individuals who, to their knowledge, had never had poliomyelitis. It is, however, recognized that persons who have never shown any paralysis may have protective substances in their blood. The serum was used in the following: (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-paralytic Cases—10 Cases. No. of Doses. Results. One nian 7 Remained free from paralysis. iiss ssi »sioniiie 9 BWO in Bnei 3 Berson bulbar symptoms within 12 hours and a 1 LEO Ua aN re i Cah EC Tg ed 10 i J 10 (b) Paralytic Cases—33 Cases. QINIDIed iv ofr vs se a hd se ae ne i 5 2 lived or i en rs 28 Of the 5 who died: 3 died within less than 24 hours after first dose of serum, 1 died of sepsis, 1 died of pneumonia. No. of Doses. Type of Cases. 275 In two of the children who died within less than 24 hours the disease was of the advanced ascending spinal form of the Landry type; in another it was of the bulbar type. There were 28 who lived. No. of Doses. Type of Cases. One iviscivssnsnns 21 Bulbar ="... .iviivies Two aun.ooi.vsouis 7 Spinal... hn. 23 8 28 There was a distinct clinical improvement in the cases that recovered, but whether more than would naturally take place without the use of serum cannot be properly claimed. II. Minturn Hospital Cases— These can also be divided into two groups: a—Pre-paralytic cases. b—Paralytic cases. a. Pre-paralytic Cases—15 Cases. Type of Serum. No. of Doses. Ee OE ee) 5 Ones. iss ole, sot Baa 5 Two lll in. 11 Cnr Los genius slvaing 1 Three. .hoo odie. 2 Diiciic dns ramainionsn 1 Fotr aves vasnsans 2 7 13 Results. (1) Remained frec-from paralysis... con iia itn 9 (2) Developed paralysis within less than 24 hours........ 2 (a) Bulbar, with complete recovery............... (B) {b) ‘Pacial, with complete TeCOVery. .. ovis sausio sets (CY {3) Developed paralysis after 4B hours... vv: vis vos as 4 (a) Facial with complete recovery................ (B) (b) Internal strabismus with complete recovery.... (C) (c¢) Both lowers and left deltoid, with marked im- Provementr sie ih Go i Ls en LS, {CO (d) Both lowers, both deltoids, with final improve- Ment ol Ee sn aaa RE eh, {CY This series represents an interesting and valuable group of cases. Each case was fully treated and carefully observed for a period of 8 weeks, and the clinical results in these children lead one to the conclusion that the serum was distinctly beneficial in the treatment of these pre-paralytic cases. b. Paralytic Cases—18 Cases. Type of Serum. No. of Doses. Type of Case. DiS ah cenit iis 3 30ne 2. Le aan, VA Bulbar lr, 2 Bi i a ps Sv Two. aS era 7 Spinal red Ranh 16 €or Ler 12. Fhree ii. viviiivie, 2 — Dri ais as vio BOUL sudessits dus 2 18 18 18 276 Results. Recovered with improvement of paralysis........ 15 Ded or ins a Fn EN de a as 3 {1ysLanhdry spinal-vos, vidi gs deals 2 (2D BUDA (Ls i St She 1 The cases in this group represent mostly the usual spinal type in an active stage of the disease, as shown by the short history and the presence of temperature. The fatal cases were seen and treated at a time when the prognosis seemed to be very doubtful. In addition to the serum treated cases there were at the Minturn ilos- pital 41 cases that received no serum. The majority of these cases came under observation during the stage of convalescence. 111. Cases treated with other physicians, outside of Department Hospitals— These cases were personally observed and treated. (a) Pre-paralytic cases. (b) Paralytic cases. (a) Pre-Paralytic Cases—14 Cases. Died. inhi ih ath Re Shin te he eas 0 Type of Serum. No. of Doses Biv ee ves One tus d. cddadive 7 Bi ces 2 TWO veevesoitioions 3 Cr a A be aS 7 Three. =... cdvvecivs 4 OF Sort cits as ond 2 _ = 14 14 Results. Remained free from paralysis............ 11 cases Developed paralysis col. ids viv ihr, 3 cases (1) Facial and strabismus with complete recovery........ (A) (2) Anterior tibial groups with marked improvement... ... (D) (3) Paresis of both upper eyelids with recovery........... (C) This group of cases treated in the pre-paralytic stage of the disease is also interesting in the large number of complete recoveries that followed the treatment with immune serum. (b) Paralytic Cases—13 Cases. Type of Serum. No. of Doses. Type of Case. 1S 0ne coves ant 6 Bulbar ives nisl 2 TWO rn a lebad 2. Bulbo-spinal .....i: 1 3 Pheer aiid im Sh eSpinal oleae -10 i 13 13 13 Results. Recovered with improvement in paralysis........ 9 Ded fo So A Ne a ed wees 4 (1) Landry spinal. cu. caro » soivis alse 3 (2) Bulan tof cA Be TR 1 277 The bulbar case died within two hours. It was a far advanced case and the prognosis was poor. Of the three Landry spinal cases, two died within less than 24 hours after treatment. In addition to these cases that were seen personally, the serum was supplied to physicians for over 200 cases. The reports obtained from the physicians are not complete, but the cases reported indicate results similar to those detailed above. Control Cases— It is very difficult indeed to state definitely to what extent the results obtained with serum can be ascribed to the action of the serum only, both as a specific and non-specific form of treatment. As stated above, the natural course of the disease is variable. For purposes of control, there- fore, a series of 12 non-treated pre-paralytic cases was taken, without selec- tion, from the records of the Willard Parker Hospital: Control pre-paralytic cases. s oui els Tsismis ss ols 12 Remained free from paralysis......... Ce 5 Developed paralysis... vows sia ces sitions sommte 7 (a) Bilateral ptosis with little movement of eyeballs. (b) Complete facial paralysis. (c¢) Paresis of right arm and left leg. (d) Paresis of right leg. (e) Paresis of neck muscles. (f) Paresis of both quadriceps extensors. (g) Paralysis of both lower extremeties. At the Minturn Hospital there were three non-paralytic cases admitted 8 days after the onset of the symptoms, who remained free from paralysis. Of two pre-paralytic cases, one developed strabismus and one paresis of both lower extremities. Summary oF Cases TREATED With (A)—IMMUNE HumMAN SERUM. Paralysis with Final Recovery. No Institution. Total. Paralysis. Complete. Partial. Died. Willard Parker Hospital... 25 24 1 0 Minturn Hospital. . ...... 15 9 3 3 0 I—Pre- With other physicians... .. 14 11 2 1 0 paralytic. —— —— — £ —_ Total avis ivan, 54 44 3 5 0 Recovered. re A eee Institution. Total. Complete. Partial. Died. Willard Parker Hospital . . . 88 5 45 38 Minturn Hospital. . ...... 18 2 13 3 II—Paralytic.{ With other physicians. .... 13 1 8 4 Total. bei. Nin 119 8 66 45 278 (B)—NormaAL HuMAN SERUM. Paralysis with Final Recovery. Institution. Total. Paradis, Com pite. Parti Died. I—Pre- } : paralytic. [Willard Parker Hospital... 10 9 pe = 1 Recovered. Institution. Total. Complete. Partial, Died. I1I—Paralytic. Willard Parker Hospital... 33 4 28 3 The above table gives a summary of the cases treated with immune and with normal human serum. It is interesting to see that of 54 pre-paralytic cases treated with immune serum 44 remained free from paralysis, while of the 10 who developed some form of paralysis, 5 made a complete final recov- ery. The results with normal serum seem to be favorable, but the number of cases treated in the pre-paralytic stage of the disease is too small, and a larger series of cases should first be treated before final deductions are made. The high mortality among the paralytic cases is explained by the desperate condition of many of the patients at the time the treatment was administered. The ascending Landry type, with involvement of muscles of respiration, or the bulbar cases, with involvement of the respiratory center, made up the majority of the fatal cases. Of the 102 cases that lived, 12 recovered com- pletely and 90 showed improvement at the time of discharge. AMOUNT OF IMMUNE AND NORMAL BrLoop OBTAINED DURING JULY, AUGUST AND SEPTEMBER, 1916. Immune Blood: (1) Convalescent blood (early)................. 16 ounces (2) Grong A BOO. cs oars on oh la esa ee 77 ounces (3) Group B.BIOO, oi cians Pe dinhnie m BabA ra os 206 ounces (4) 'Gronp CDIood ci sih side siahis hs ni isis Sakai 643 ounces (3) Group D.hIood. + viv smevinssinibhh oasis as 314 ounces Oil i ein i ibis, ois eee ie ea rds 1,256 ounces Normal Blood: FE DeNOLs 2 us rn aE A ns Se 144 ounces SumMARY OF RESULTS. It is known that in poliomyelitis we have a group of non-paralytic or abortive cases which go through the premonitory symptoms, but do not terminate in paralysis. It is impossible to state, therefore, how many of 279 the cases treated with serum would have remained free from paralysis without serum treatment. The results and the conclusions from any form of treatment in a disease which is so varied, variable both in symptomatology and in prognosis, as to life and as to function, must be given with reserve. The results obtained seemed to be favorable when the serum was used in suitable cases in the pre-paralytic stage of the disease. Paralysis has been followed in some cases, but the mortality seems to have been influenced by the administration of serum. The later and more severe cases treated after the paralysis had already made a distinct headway and was beginning to involve the muscles of respira- tion, showed, in a certain proportion of cases, an inhibitory effect of the serum upon further progress and a possible life saving result. While no absolute judgment of the value of a serum can be based as yet upon the results obtained, they are, nevertheless, encouraging and justify a continuation of the serum treatment in acute poliomyelitis until, in the course of time, more definite data be available. SERUM THERAPY IN EXPERIMENTAL POLIOMYELITIS. The blood of persons who have survived an attack of acute poliomy- elitis contains specific substances which possess the ability of neutralizing active poliomyelitis virus. This has been demonstrated by Flexner and Lewis, Romer, Landsteiner and Levaditi, et al. It has also been shown that monkeys recovering from an attack of poliomyelitis become refractory to a second inoculation of virulent material, and in the blood of these animals can be demonstrated the neutralizing principles found in the blood of recovered human cases. Netter (1) applied this knowledge in the treatment of a small series of human cases, with perhaps favorable results. His conclusions were not very definite. He administered, intraspinally, from 4 to 12 c.c. of serum obtained from a recovered case whose blood yielded a negative Wasser- mann. It was administered daily for four or five days, or as long as the clinical symptoms indicated its need. One case received eight injections. Zingher (2) treated a larger number of cases by the intraspinal method, using sera obtained both from recovered cases of the disease and from normal persons. His report is favorable to the treatment. No tests were made to determine whether or not the sera obtained from the recovered cases possessed the neutralizing powers necessary to render it specific. Two cases of reinfection in the epidemic of the past summer that had come to our attention may throw some doubt on the assumption that all cases that recover from one attack of the disease are immune to a second infection, or that the blood of all such cases possesses neutralizing powers. However, the testing of the serum of each donor, for the specific prin- ciples would render the whole procedure impracticable, mainly because of (1) Netter, Bull. de I'Acad. de Med., 1914, IXVI, p. 525. (2) Zingher, Journ. Am. Med. Assn., March, 1917. 280 the loss of time necessary to perform this test, and secondarily, because of the expense, for at the present time there is no way of demonstrating this property in serum, except by the injection into a monkey of active virus that had been placed in contact with the serum. From a practical viewpoint the probabilities are that only a small percentage of the cases would give a negative test. Schwarz (3) treated 21 cases with convalescent human serum. Of these, nine recovered without paralysis. Of a series of 21 other cases treated expectantly 17 recovered without paralysis. From this might be inferred that the serum was not of any particular advantage. Schwarz feels that too much was not to be expected of the use of the immune serum. Prognosis in poliomyelitis is a very difficult matter. It will require, ‘therefore, great numbers of cases adequately controlled to gain a true idea of the value of the serum treatment from the clinical viewpoint. The clinical use of the serum of old recovered cases of poliomyelitis is not founded on complete, clear-cut animal experimentation. Its use is in part scientific and in part empirical. Flexner (*) and Lewis performed two experiments, the results of which indicate that a known specific serum may exert a prophylactic effect. An effective dose of active serum virus was injected intracerebrally into a monkey. Within twenty-four hours after the inoculation, and daily there- after, the animal received intraspinal injections of immune serum for a number of days. This animal remained healthy, whereas the control died. Another monkey was inoculated by intranasal scarification with a potent virus. This animal received intraspinal injections of immune serum, within 24 hours after the inoculation, and at three day intervals for a number of injections. This monkey did not exhibit any symptoms of poliomyelitis, while the control died of the disease. The authors state that if the amount of virus injected is not in excess of a certain amount, the procedure de- scribed above will serve to protect animals injected with such a quantity of virus. . The conditions of these experiments, however, do not parallel those which are met with when dealing with actual human cases, where the virus has already become established and is multiplying in the central nervous system, as evidenced by the symptoms of the disease. In this instance, the specific serum can no longer prevent, it must cure. It must counteract and nullify virus that has already become parasitic, and that may have increased in amount, perhaps, in excess of that which can be taken care of by injections of known immune serum. The present work in experimental serum therapy was undertaken in an attempt to supply the conditions that are met with in actual practice. This work comprises six experiments, in each of which were used two animals. One animal was serum treated, and the other acted as control. The virus (3) Schwarz, Archives of Pediatrics, Nov., 1916, Vol. 33, No. 11, p. 859. (4) Flexner and Lewis, Jr., of A. M. A.,, May 28, 1910, Aug. 20, 1910. 281 was an emulsion of brain and cord material derived from the epidemic of the past summer. Virus of the second generation was used in the first series, and the virus of each succeeding generation was used in the remain- ing experiments. The amount of virus injected was not determined from very much previous experience with this strain. That the dosage was not excessive is evidenced by the fact that two of the control animals, Nos. 37 and 54, and Nos. 23 and 24, not used in these experiments, but which re- ceived the same amounts of virus, survived the disease. The serum used in these experiments was obtained by heart-puncture from monkeys, Nos. 98 and 102. Both of these animals were resistant to the effects of three inoculations of brain and cord material. This material was inoculated in very heavy suspensions, intracerebrally, in the tissues about the sciatic nerves and in the peritoneum. The material, for the first two inoculations, was obtained from two human cases, clinically and pathologi- cally poliomyelitis. The third inoculation was made with material of the second generation monkey virus. These inoculations were given three weeks apart. It was assumed that as a result of these three inoculations, these monkeys were immune and that the blood of these animals ought to contain the specific antibodies. No neutralization test was performed on the sera used in this set of experiments. This, in a measure, parallels the clinical use of serum by Netter and Zingher. In a series of experiments now under way, we shall have the oppor- tunity of observing the effects of known monkey and human immune serum, in the experimental serum therapy of monkey poliomyelitis. Method of Injection. The serum was injected by syringe in doses of 2 to 324 c.c., depending upon the size of the animal and resistance offered to the plunger of the syringe. As much spinal fluid as possible was withdrawn, usually with the aid of the syringe. The first tap yielded up to 2 c. c. of slightly turbid fluid, but subsequent punctures yielded from 25 to 1 c.c. of fluid. The fluids, on being examined, when the quantity was sufficient, gave a globulin test and a definite increase in cells, in one instance, 690 cells per cu. mm. The serum, was injected very slowly and with extreme caution against using any excess pressure. Only one animal exhibited severe effects after the intraspinal injection. This consisted of marked rigidity of limbs, retracted neck and labored and rapid respiration. These symptoms, however, were very transi- ent and within half hour after the injection, the monkey appeared as before the injection. Retraction of the neck was noted after many of the injec- tions, particularly after the symptoms of paralysis had appeared. Time of Injection. The time periods elapsing between the injection of the virus and the beginning of the intraspinal serum injections was so arranged as to be ap- plicable to conditions met with in actual practice. In the Experiments I 282 and II, the serum treatment was begun on the first day of the appearance of any muscular weakness. In the remaining four experiments, serum treatment was instituted before any symptoms had appeared, corresponding to the pre-paralytic stage in the human disease. The protocols are as follows: Experiment I.— Sept. 1, 1916. Rhesus No. 50. Injected with 4 c.c. intraspinally, 2 c.c. perisciatic and 10 c.c. intraperitoneally, of suspension lI. gen. virus. Rhesus No. 51, control, received 1.2 c.c. intracerebrally, of the same emulsion. Sept. 6, 1916, No. 50 appeared sick and limped on left leg. Received 31% c.c. serum No. 102, intraspinally. Sept. 7, 1916, 3% c.c. serum No. 102, intraspinally. Limp still present. On Sept. 10, limp was not noticeable and animal appeared strong and healthy. Sept. 5, 1916, Rhesus No. 51, control, exhibited general tremors and marked muscular weakness. No definite paralysis. Died Sept. 8, 1916. Congestion of the pia and swelling and redden- ing of gray matter of cord. The virus of this monkey subsequently produced typical flaccid paralysis. : Whether or not Rhesus No. 50 really had poliomyelitis, it is difficult to judge. He did not at any time present frank paralysis and his rather rapid recovery is suspicious. This animal was one of whose past history we knew nothing. Experiment 11. — Sept. 21, 1916. Rhesus No. 27, 14 c.c. intracerebrally and 2 c.c. perisciatic, of 10 per cent. virus, III. gen. Rhesus No. 26, control, 14 c.c. intracerebrally, same virus. Sept. 28, 1916. Rhesus No. 27, weakness of left leg; 272 c.c. serum No. 102, intraspinally. Rhesus No. 26, control, paralysis left and weakness right leg. Sept. 29, 1916. Rhesus No. 27, paralysis both legs, weakness left arm; 27% c.c. serum No. 102, intraspinally. Rhesus No. 26, paralysis both legs, left arm, weakness right arm; difficulty in breathing. Sept. 30, 1916. Rhesus No. 27, complete paralysis of limbs and diaphragmatic breathing. Died. : Rhesus No. 26, respiratory failure. Died. The incubation period in both of the above animals was eight days and duration of illness three days. Experiment 11]. — Oct. 2, 1916. Rhesus No. 36, 5 c.c., 10 per cent. virus, IV. gen., intracerebrally. Rhesus No. 37, control, 2 c.c. same suspension, intracerebrally. Oct. 7, 1916. Rhesus No. 36, apparently normal; 3 c.c. serum No. 102, intraspinally. Rhesus No. 37 well. Oct. 8, 1916. Rhesus No. 36 well; 3 c.c. serum No. 102. Rhesus No. 370. K Oct. 9, 1916. Rhesus No. 36, paralysis both legs, weakness left arm; 2% c.c. serum No. 102. Rhesus No. 37, control, paralysis left leg, weakness right leg. 283 Oct. 10, 1916. Rhesus No. 36, complete paralysis both arms and legs; breathing with difficulty; no serum, condition bad. Rhesus No. 37, paralysis both legs, weakness left arm. Does not appear as sick as No. 36. : Oct. 12, 1916. Rhesus No. 36 died, respiratory paralysis. Rhesus No. 37, paralysis both legs, weakness left arm. Cessation of progress of paralysis. Nov. 29, 1916. Rhesus No. 37 alive. Permanent paralysis in legs. Left arm O. K. In the above experiment, Rhesus No. 36 received serum treatment on the 5th day after injection of virus and two days before the onset of paralysis. Rhesus No. 37 control, exhibited paralysis on the same day as No. 36, an incubation of 7 days. The serum treatment apparently had no influence on the incubation period. Furthermore, No. 36, despite three treatments, suffered a rapidly spreading fatal form of the disease, whereas No. 37, control, survived the same injection, but with residual paralysis. Experiment 1V.— Oct. 13, 1916. Rhesus No. 43, 75 c.c. 10 per cent. gen. V. virus, intracerebrally. Rhesus No. 42, control, very large animal, 1 c.c. intracerebrally and 5 c.c. intraperitoneally of same virus. Oct. 18, 1916. Rhesus No. 43 received intraspinally 3 c.c. serum No. 102. Oct. 21, 234% c.c. serum No. 98. Oct. 22, 2 c.c. serum No. 98. No signs of disease during this period.. Rhesus No. 42, control, pre- sented no symptoms. Oct. 23, 1916. Rhesus No. 43, left leg paralyzed and weakness in right leg; 2 c.c. serum No. 98, given intraspinally. Rhesus No. 42 shows no symptoms. Oct. 24, 1916. Rhesus No. 43, paralysis progressing; 2745 c.c. serum No. 102 administered. Rhesus No. 42 apparently well. Oct. 25, 1916. Rhesus No. 43, paralysis involving both arms and legs; 3 c.c. serum No. 102 given. Rhesus No. 42, control, shows weakness in left leg. Oct. 27, 1916. Rhesus No. 43 died of respiratory paralysis. Rhesus No. 42 presents involvement of both legs and weakness of left arm. Oct. 31, 1916. Rhesus No. 42 died of respiratory paralysis. In the above experiment, the serum-treated animal began to receive intraspinal injections of serum on the Sth day after the injection of the virus and five days prior to the appearance of symptoms in the same animal, and 7 days before the control animal exhibited muscular weakness. Fur- thermore, the control animal had several times the dose of virus received by the test animal. The progress of the disease was more rapid in the serum treated animal, which terminated on the 5th day of the disease, than in the control animal, which died on the 7th day of the disease. Experiment V.— Nov. 2, 1916. Rhesus No. 52, 75 c.c. of 10 per cent. VI. gen. virus, intracerebrally. Oct. 31, 1916. Rhesus No. S, large animal, control, 74 c.c. intra- cerebrally and 5 c.c. intraperitoneally, of 10 per cent. VI. gen. virus used on No. 52. 284 Nov. 8, 1916. Rhesus No. 52, apparently normal, received 214 c.c. serum No. 102 intraspinally. Rhesus No. S, control, showed paralysis left arm. Nov. 9, 1916. Rhesus No. 52, paralysis of left leg; 214 c.c. serum No. 102. Rhesus No. S, paralysis of all limbs and respiratory paralysis. Died. Nov. 10, 1916. Rhesus No. 52, paralysis progressing; 215 c.c. serum No. 102. Nov. 11, 1916. Rhesus No. 52, paralysis of both legs, left arm; 2 c.c. serum No. 98 administered. Nov. 13, 1916. Rhesus No. 52, complete paralysis, including muscles of respiration. Died. Though Rhesus No. 52 received a smaller dose of virus and one injec- tion of serum on the sixth day after the inoculation, the incubation period was seven days, whereas in Rhesus No. S, with larger dosage and no serum therapy, the incubation was nine days. This animal, however, suffered a fulminating type of disease, dying on the second day after the appearance of symptoms. This was probably due to the early involvement of muscles of respiration. The serum treated animal died on the fifth day of the disease. Experiment VI.— Nov. 10, 1916. Mangabey No. 53, 15 c.c. 5 per cent. VII. gen. virus, intracerebrally. Mangabey No. 54, control, 1=2 cc. 5 per cent. same virus intracerebrally. Nov. 15, 1916. Mangabey No. 53 appears well; 3 c.c. serum No. 102 intraspinally. Nov. 16, 1916. Mangabey No. 53, 3 c.c. serum No. 102; appears normal. Nov. 17,1916. Mangabey No. 53, paralysis of left leg; no serum. Nov. 18, 1916. Mangabey No. 53, paralysis progressing ; 25 c.c. serum No. 98. Mangabey No. 54, weakness left leg. Nov. 19, 1916. Mangabey No. 53, paralysis both legs and left arm; 2 c.c. serum No. 98 administered. Mangabey No. 54, marked weakness in left leg and slight weakness in right leg; progress of paralysis slow. Nov. 20, 1916. Mangabey No. 53 lies prone, does not stir body, moves right arm weakly; tremor of head. Mangabey No. 54, con- dition about the same. Nov. 22, 1916. Mangabey No. 53, complete paralysis; died. Mangabey No. 54, weakness in legs more marked. Nov. 25, 1916. Mangabey No. 54, progress of involvement slow ; shows slight weakness of left arm; tremor of head. Nov. 27, 1916. Mangabey No. 54 shows signs of improvement; left arm apparently stronger, as is also the right leg. Dec. 1, 1916. Mangabey No. 54, improvement marked; feeds well; can sit up without great difficulty ; will probably recover. In the foregoing experiment, the test animal received serum treatment on the fifth day after the injection of virus and two days before symptoms of the disease appeared in an incubation of seven days. The disease ran 285 . a progressive fatal course despite four injections of serum. The control animal showed evidence of paralysis on the eighth day after infection, with slowly progressing symptoms and with subsequent improvement. This animal is alive at this writing. Summary. The summary of the results of the foregoing experiments is as follows: Five of the six serum treated animals died, a mortality of 83 per cent. Four of the six control animals died, a mortality of 66 per cent. Of the four animals that received intraspinal serum therapy before the appearance of paralysis, one received 1 treatment, two 2 treatments and one 5 treatments in the pre-paralytic stage. In one of these the incuba- tion period was the same as in the control animal. In the remaining three, the incubation was shorter by one to two days than in the control animals. The duration of the disease in the serum treated animals was somewhat shorter than in the controls, varying from two to six days, whereas in the latter the acute progressive stage was from three to eight days, indicating a greater rapidity in the spread of the disease in the central nervous system. The number of serum administrations varied from two to eight, depending upon the condition of the animal. They were discontinued when the animal exhibited distinct signs of improvement, or when the paralysis had progressed to respiratory difficulty. Discussion. Experimental poliomyelitis is several times more fatal a disease than human poliomyelitis, and perhaps it is rather severe on the clinical use of unknown “immune ” serum to compare it with experimental use of a like serum in monkey poliomyelitis. However, that seems to be the only method known at the present time of gaining any correct idea of the value of this method of treatment. An effort was made in the foregoing experiments to parallel clinical conditions. Two of the animals were injected with serum on the first day of the appearance of paralysis and four from five to six days after date of infection, but in the pre-paralytic stage. The test animals were controlled by six animals that received no serum therapy. : Comparison of effects of the disease in the serum treated animals as against the effects observed in the control animals, would incline one to the inference that, at least in the experimental disease, intraspinal injections of serum are not only of no value, but also that there may be in them an element of harm. The mechanism producing the untoward effects has not been demon- strated, but it may consist in the exaggeration of the pathological process already existing by the introduction into the subdural space of a foreign substance. Marked meningeal symptoms have been observed following the introduction of serum, both in the experimental and human disease. In some instances the spinal fluids obtained after the injection of serum have 286 shown distinct evidence of accentuated inflammatory reaction, as indicated by increased morbidity, due to increase of cellular elements; increase in the content of albumin and globulin. That this meningeal reaction may have a delaterions influence on the already existing pathologic process in the cord and brain proper is not without plausibility. Careful comparative study of the nervous tissues of the serum treated and the control animals may indicate whether or not this is the true explanation. In the minds of the general public and of most physicians, there exists a close analogy between the use of serum in epidemic meningitis and in poliomyelitis, and its success in the former has influenced them to have faith in the success of the latter. The pathology of the two conditions, however, is quite different. In acute purulent meningitis the process is limited almost entirely to the meninges, the brain and cord substance being little if at all involved, though there may be some secondary congestions. In poliomyelitis the pathological picture is reversed. Here the brain and cord substance is mainly involved, whereas the inflammation in the meninges is entirely secondary. Injecting a foreign substance into the slightly in- flamed meninges sets up in most cases an acute aseptic meningitis, as is shown by changes in the spinal fluid, and clinically, by increased tempera- ture, rigidity of the neck and other signs of meningeal irritation. It is reasonable that this increased inflammatory reaction should tend to accentu- ate the inflammatory changes existing in the subjacent substance of the brain and cord. This is contrary to the commonly accepted idea that the first indication in the treatment of an inflammation is rest. And that this reaction may be harmful is borne out by the results of animal experimenta- tion. In meningitis, on the other hand, the injection of serum into actively inflamed meninges is not followed by an increase in the inflammatory reaction, as is evidenced by the clearing up of the fluid and the amelioration of the clinical symptoms in favorable cases. It would seem, therefore, that from this point of view the action of the serum may even be distinctly harmful. As to its specific neutralizing power, this would have to be exerted very speedily, since the damage is so often done within 48 or 72 hours after the onset of symptoms. SUMMARY OF EXPERIMENTS ON INTRASPINAL TREATMENT WiTH UNKNOWN “IMMUNE” SERUM. In these cases, history of disease by patient not verified by tests for antibodies. SERUM INJECTION VIRUS INJECTED. INTRASPINOUSLY. PARALYSIS. Duration Incuba- 0 No. Gen. Amount. Site. Date. Date. Amount, Bojirce. Date. tion. Disease. Character, Extent. Outcome o. 50 Rhesus II % c.c. 10% Brain ] Sept. 6,1916 3% c.c. 102 Sept. 6, 1916 5 days 2 days Slight weakness in left leg. Alive and 2 c.c. 109, Sciatic Lisi 1, 1916 Sept. 7,1916 34 cc. 102 well 10 c.c. 109%, Peritoneum ; 51 Rhesus II Yc.c. 10% Brain Sept: 1 L036 ci ire die Li i . Sept. 5,1916 4 days 3 days General muscular weakness, Maran- Died Control tic type. Sept. 8, 1916 27 Rhesus III Y% c.c. 10% Brain 1 Sept. 28, 1916 214 c.c. 102 Sept. 28,1916 8days 3 days Rapid progressive paralysis left leg, Died 2 ¢.c. 10% Sciatic /Sept. 21, 1916 Sept. 29,1916 2}5c.c. 102 right leg, left arm and right arm Sept. 30,1916 Respiratory failure. 26 Rhesus IIT % c.c. 10% Brain Sept: 21,1916 5. i ra ER . Sept. 28,1916 8 days 3 days Rapid progressive paralysis, left leg, Died Control right leg, left arm, right arm. Sept. 30,1916 Respiratory failure. 36 Mac IV 15 c.c. 109% Brain Oct. 2,1916 Oct. 7, 1916. 3c.c. 102 Oct. 9,1916 7 days 4 days Rapid progressive paralysis beginning Died Rhesus Oct. 8, 1916" 3 cc... 102 with left leg, right leg, left arm, Oct. 12 Oct. 9,1916 2¥ cc. 102 right arm. Respiratory paralysis. 37 Rhesus IV Y%c.c. 10% Brain Oct 2, TBE av wen’ dded ... Oct. 9,1916 7 days 4 days Pros. flaccid paralysis beginning leftAlive; has Control acute leg, right leg, left arm, then re- diplegia gression. 43 Rhesus V Y%c.c. 10% Brain Oct. 13,1916 Oct. 18 3cc. 102 Oct. 23,1916 10days 5days Progressive flaccid paralysis begin- Died ct.’ 19 2%cc. 102 ning with left leg, then right leg,Oct. 27, 1916 Oct. 20 cc 102 then left arm, then right arm. Oct. 21 2%cc. 98 Respiratory failure. Oct. 22 2cc. 98 Oct. 23 20.0. 98 Oct. 24 2% c.c. 102 Oct. 25 cc. 102 42 Giant V 1c.c10% Brain Oct 413, 1916-7. Jf Ab Ba de ... Oct. 25,1916 12 days 7 days Progressive spinal paralysis, begin- Died Rhesus 5 c.c. 109% Peritoneum ning with left leg, then right leg; Oct. 31, 1916 Control simultaneously in both arms. Repsiratory failure. 52 Rhesus VI Y%c.c. 10% Brain Nov. 2,1916 Nov. 2% c.c. 102 Nov. 9, 1916 7 days 5 days Progressive spinal, beginning with Died Nov. 9 23% cc. 102 left leg, right leg, left arm, right Nov. 13, 1916 Nov. 10 2l4cc. 102 arm. Nov. 11 2¢.0.. 98 S Rhesus VI ¥%c.c. 10% Brain Nov. 2,1916 ...ccovvvvvr cnnens . Nov. 8,1916 9days 2days Rapid progressive spinal, beginning Died (Large) 5 c.c. 10% Intraperi- with left arm, then right, then Nov. 9,1916 Control toneally respiratory failure. 53 Mangabey VII ¥% c.c. 5% Brain Nov. 10, 1916 Nov. 15 3c.c. 102 Nov. 17,1916 7 days 6 days Progressive spinal paralysis, begin- Died ov. 16 EAT 102 ning with right leg, left leg, left - Nov. 22, 1916 Nov. 18 24ce. 98 arm, right arm. Respiratory Nov. 19 2cc. 98 failure. 54 Mangabey VII Y cc. 5% Brain Nov. 10, 1916 «..oavie iiss savas . Nov. 18,1916 8days 8days Progressive spinal paralysis, begin- Al ive and ontrol ning with left leg, weakness right leg and left arm, slight weakness in right arm. Improving L8¢ 288 2. ORTHOPEDIC TREATMENT. In the orthopedic treatment of poliomyelitis at the Willard Parker Hospital it was found best to allow all cases to remain undisturbed in bed during the presence of acute symptoms, as fever, pain, etc. At the end of this time, usually about one week, each case was carefully examined by the attending orthopedic surgeon to determine the extent of the paralysis and to decide upon the best means of supporting the involved muscles, to relieve strain, and to prevent deformity. For cases with involvement of neck and back muscles and those with the more marked meningeal symptoms, a frame bent to coincide with the contour of the back was found most effectual for relieving the strain on the muscles and also alleviating the pain, which was often very severe. For involvement of neck muscles, a light plaster collar with sometimes a hood attachment was applied. Plaster casts and moulded plaster splints were applied to paralyzed extremities. All forms of support were removed at frequent intervals to enable the patient to practice voluntary movements, to preserve joints, and to guard against decubitus, which was apt to occur very quickly in the more severely ill cases. It was interesting to note that many very fretful children immediately became quiet and contented when proper support was supplied. During the fifth week all patients with paralysis still present were care- fully examined with a view of determining the best form of future treat- ment. We attempted to classify them as follows: Those patients with extensive paralysis who are unable to hold the body erect and for whom any immediate form of ambu- latory treatment is impossible. cui iri. wile sania ie + 6 cases Patients with slight paralysis or weakness in whose muscles DOWEL 1s rapidly: vetting Sei iaiet i ions niente nate winfain on wink 1443 cases Patients whose paralyzed muscles apparently do not exhibit any sign of returning power and the paralysis might be consid- ered Wore OF. Jess permanent.) mis » sil, sidiintan bite wales 9 cases Patients with marked paralysis but with some returning power, in which recovery would probably take months or a year OTEEWO Sv oth oad hove wie hi an oe bh nite m ie ved awe en Al al 249 cases Patients in group one were discharged with plaster supports. It was recommended that these patients receive continued hospital care if possible. Group two patients were discharged with plaster splints if necessary and were referred to a neighboring clinic for continued supervision. Patients in group three were carefully fitted with braces with lock joints, etc., and crutches if necessary. Those in group four were fitted with a less expensive but suitable type of brace, as it was thought probable that the brace would be unneces- sary after a few months. 289 Children under one year of age were discharged with light plaster sup- ports. A few adults who might be classified in group one were equipped with braces and crutches to enable them to stand up and perhaps take a few steps, but more especially to obviate possible domestic difficulties and to prevent, if possible, that condition of mind so frequent in those hopelessly bedridden. The paralysis about the shoulder seemed slowest to improve. For these cases a brace which would hold the arm at right angles to the body was prescribed. A short leg brace with a stop to prevent foot-drop was used in cases of paralysis of the anterior tibial group, or the stop was reversed when the posterior tibial group was involved, or a double stop when both groups were involved, a straight brace extending up the thigh, allowing no motion at the knee, was used when the flexors or extensors of the leg are involved. For cases in group three this brace, with a movable joint which locks in extension, was used. Those cases with involvement of the rotators of the thigh, and muscles about hip-joint, were equipped with a brace extending up to the pelvis and having a pelvic band. The motion in this brace at the hip is adjusted to the requirements of the case. If both lowers are involved a double brace may be used. These cases were also equipped with crutches if necessary. It has been observed in numerous instances that the paralysis has greatly improved as soon as the patient has gotten up and about with the brace. This is well shown by the large numbers of cases in which it has been possible to cut down the brace, lessening the number of muscles sup- ported by it or, as in many cases, to entirely dispense with the brace. We believe that the effort to maintain equilibrium and to get about supplies a stimulus such as no other method of treatment can supply to the nerve centers, nerves, and muscles, and possibly facilitate the opening of new paths for the transference of motor and trophic impulses to the muscles. The patients to whom we have supplied braces are being visited at their homes, to make sure that the brace is being properly worn and that instructions as to bathing, exercise and massage are properly carried out. CHAPTER XIII. Prophylaxis. Poliomyelitis being an acute infectious disease, it follows as a logical consequence that the same sanitary measures must be employed, and the same regulations enforced, for the prevention of its spread as for the pre- vention of any other acute infectious or communicable disease, isolation, disinfection, etc. It is obvious from what is known of the nature of the infection, that segregation and other similar measures approaching complete control, must be impracticable, as segregation to be effective in poliomyelitis must include not only paralytic, but also non-paralytic or abortive cases, and the healthy carriers of the virus; nor is there any specific antitoxin or protective vaccine against the disease upon which we can rely for the im- munization of exposed susceptibles. Under these circumstances, as soon as the Department of Health real- ized that it was facing an outbreak of poliomyelitis, it took steps to pro- vide for the enforcement of the necessary general sanitary measures for the prevention of its spread. The first step toward the attainment of this object was, primarily, to enlist the co-operation of the medical profession in the work that had to be performed ; secondly, to instruct the public as to the reasons for the necessity of its performance. For this purpose, in addition to the exaction of the usual requirement that all recognized and suspected cases of the disease be promptly reported, there was issued, early in July, a circular of “ Infor- mation for Physicians Regarding Poliomyelitis (Infantile Paralysis),” stat- ing what was known concerning the causes, modes of infection, transmis- sion and symptoms of the malady, and giving directions as to the general care of the patients. Later, there was issued another circular of “ Informa- tion for the Public Regarding Infantile Paralysis (Poliomyelitis),” describ- ing in simple, non-technical language the early symptoms of the disease and- its communicability through the discharges of the nose, throat and bowels of those ill with the disease to well persons, and laying especial stress upon its transmissibility by means of non-paralytic cases and healthy persons from sick persons with whom they were associated. Instructions were also given how to guard against the disease, what to do in cases of sickness and what the Health Department would do. A copy of these circulars and other special information regarding procedure in poliomyelitis regulations governing quarantine, removal, care and treatment of persons suffering from the disease, etc., issued by the Department of Health, will be found in the appendix. These procedures for the prevention of the spread of infection were strictly enforced and the physicians of the city, appreciating the situation, willingly lent their aid toward the support of the health authorities. 291 To cite an instance of this support in the matter of reporting cases: From August 5th to December 16th, 1916, inclusive, a record was kept by the Department of all the field assignments given inspectors for investiga- tion of reports from all sources, of poliomyelitis or suspected poliomyelitis cases, together with the number found by diagnosticians to be true cases. This record shows that as the epidemic advanced the percentage of true poliomyelitis cases to assignments perceptibly diminished; in other words, that an increasing number of suspected cases were reported by physicians as their knowledge and interest grew with the extent of the epidemic. The figures given below include all cases reported from August 5th to December 16th, with the exception of one week in August, for which the data are not available: Percentage of True Poliomyelitis to Inspections. Assignments. True Cases. Percentage. August (iromiSth). .voniiubi aire sasinst von 5,208 2973 57 SCDLEMIDRY. - + 0 Soveitivins sore trsbidhscnbusets v. + ncharia i ee 2,382 1,345 .56 October: «alas Ahatli vrs nt 3 529 248 .46 NOVEMDEr os oa filo uid Dork ried si 8 2 ds si ins sos 136 46 33 Pecember="", i cause susie saiee ia ¢ Earner o ¥ vas 50 18 30 otal igs a a ad 8,305 4,632 55 During the epidemic, including a period of sixteen weeks, whenever a case of poliomyelitis was reported a careful survey was made of every stable within a radius of four blocks. In these stables, when an insanitary condition was found, frequent reinspections were made until the nuisances were abated. Thus a total number of 10,996 inspections were made in 5,142 stables; unclean stalls, runways, floors, ceilings and walls were carefully inspected, manure removed, yards cleaned, etc. The street car lines were inspected and orders issued to have the cars cleansed carefully and thoroughly at least once a day and maintained in a cleanly condition at all times. The food stores in the city and the various places where food is kept or handled, were carefully inspected and special provision was made to insure the sanitary condition of all foods and drinks distributed during the epidemic. As a result of this active and vigorous work for health and cleanliness, on the part of the health authorities, and especially because of the campaign of publicity and education conducted through the Department’s Bureau of Public Health Education, the whole city was aroused to interested participa- tion in the work of sanitation. It was observed by everyone acquainted with ordinary conditions that the city was never before so clean; that tene- ment houses were never so clean; parents were never so careful about their children, food was never so generally kept covered and kept clean, and 292 sound medical advice was never so eagerly sought or so well followed. Moreover, sanitary regulations were never so easily enforced as during the epidemic. The violations that occurred were due mainly to oversight and not to indifference or wilful disobedience. Nor were other organizations behindhand in furthering the work of sanitation. Invaluable aid was rendered by practically all the other municipal departments, and by many private associations. The streets were flushed daily, tenement houses were inspected and violations of the law directed and remedied. Hospital care was provided for thousands of patients—besides the large number of cases treated in the Department of Health hospitals, many additional cases were admitted to 28 or 30 other hospitals in the city. Automobiles and ambulances were turned over to the Health Depart- ment to use for this work. Orders for large amounts of printing were hur- ried through. Funds were provided and additional physicians, laboratory workers, nurses, domestics and others were employed. A host of volunteers aided in the distribution of health leaflets; and press and pulpit zealously joined in preaching the propaganda of prophylaxis. Altogether the com- munity set an example of co-operation for health and civic betterment which deserves the highest commendation. This work of co-operative sanitation, instigated by the stimulus of a dreaded disaster, not only succeeded in checking the visible calamity, but it produced an unseen and unexpected result which was even more remarkable in its effects. Notwithstanding the prevalence of the epidemic of polio- myelitis—a disease which fatally affects young children in particular, 80 per cent. of those attacked dying from it in the first five years of life—both the mfant mortality and the general death rates of the city were as low or lower, throughout the summer of 191€, than they were during the same period of 1915, when there was no epidemic to contend with. The table (p. 295) giving the official mortality statistics for the City of New York, for 1915 and 1916, demonstrates these remarkable results in figures that cannot be controverted. Commentary is unnecessary with such facts as these to prove the efficacy of co-operative sanitation in public health work. Unfortunate as the recent epidemic undoubtedly was, and in some respects unproductive from an epidemiological point of view, this disastrous visitation may yet turn out to have been a blessing in disguise, if it fixes indelibly in our minds one obvious and incontestable truth—that the control not only of polio- myelitis, but of all preventable diseases, does not depend upon the mysterious power of any supernatural agency, but that the remedy lies largely within ourselves. “Our remedies oft in ourselves do lie, Which we ascribe to heaven: the fated sky Gives us free scope; only doth backward pull Our slow designs, when we ourselves are dull.” 293 APPENDIX. Names of Members of Committees in Connection with Poliomyelitis Epidemic. Committee on Infantile Paralysis—Advisory Council. Dr. Louis C. Ager, Chairman * Dr. Simon Flexner.* Dr. Elias H. Bartley. Dr. Royal S. Haynes. Dr. Robert O. Brockway. Dr. Henry Koplik. Dr. Eugene S. Dalton. Dr. Howard Mason. Dr. Thurston H. Dexter. Dr. Herman Schwarz. * Dr. A. H. Doty. Dr. J. T. Simmonson. Dr. George Draper. Dr. Rudolph F. Rabe. Dr. 8: J. Baker. Dr. 1. S. Billings. x Dr. S. R. Blatteis. Representatives Dr. Charles F. Bolduan.* of the Dr. George L. Nicholas. Department of Health. L Dr W. 31 Park. Dr. B. S. Waters. Dr. R. J. Wilson. Mayor's Committee on the Epidemic of Poliomyelitis (to Act as His Advisers During the Epidemic). Dr. E. H. Bartley. Dr. Henry Koplik Dr. John W. Brannan. Dr. Samuel Lambert Dr. Leland E. Cofer. Dr. C. H. Lavinder Dr. H. B. Delatour. Dr. Leon Louria Dr. A. H. Doty Dr. William H. Park Dr. George Draper Dr. Antonio Stella Dr. Simon Flexner. Dr. J.-M. Van Cott Dr. S. S. Goldwater. Dr. Philip Van Ingen Dr. Walter B. James Committee on Research on Poliomyelitis. Dr. H.'L. Amoss. Dr. Josephine B. Neal. Dr. George Draper. Dr. William H. Park. Dr. W. H. Frost. Dr. Hans Zinsser. Dr. C. H. Lavinder. * These had been members of the Collective Investigation Committee which studied the 1907 epidemic. 294 Orthopedists Connected With Department of Health Hospitals. Dr A-H.Cilley....0..00 Riverside Hospital. De. J. J. Nutt. nn. 0h Willard Parker Hospital. Dr. Henry Ling Taylor.. Queensboro Hospital and Swinburne Island. Dr. D. Traslow. m0 Kingston Avenue Hospital. Committee on Permanent Relief and Follow-up Care. Miss Bessie Amerman, Henry Street Settlement. Dr. Oliver Bartine, Hospital for Ruptured and Crippled. Dr. Henry W. Frauenthal, Dispensary and Hospital for Joint Diseases. Miss Jessie M. Hixon, Association for Improving the Condition of the Poor, Brooklyn. Dr. John R. Howard, Jr., N. Y. Orthopedic Dispensary and Hospital. Miss Bessie LeLacheur, Association for Improving the Condition of the Poor, Manhattan. : Dr. Thomas J. Riley, Brooklyn Bureau of Charities. Dr. Jacques C. Rushmore, Long Island College Hospital. Dr. Reginald H. Sayre, Attending Orthopedist, Bellevue Hospital. Dr. J. D. Steinhardt, Bronx Hospital and Dispensary. Dr. Walter Truslow, Kingston Avenue Hospital. Dr. Morris D. Waldman, United Hebrew Charities. Dr. Donald E. Baxter, Director of Committee. Committee on House to House Visits. ORGANIZATIONS REPRESENTED. Associated Charities of Flushing. Brooklyn Association for Improving the Condition of the Poor. Brooklyn Bureau of Charities. Charity Organization Society of New York. Henry Street Settlement. Metropolitan Life Insurance Company. New York Association for Improving the Condition of the Poor. United Hebrew Charities of New York. United Jewish Aid Society of Brooklyn. University Settlement Society. 295 Death Rates by Months at All Ages and Under One Year of Age. City of New York—1915 and 1916. 1015, 1916. Death Rate Death Rate Rate Under Rate Under Per ~~ Deaths 1 Year Per Deaths 1 Year Deaths. 1000 Under of Age 1000 Under of Age All Popula- 1 Year Per 1000 All Popula- 1 Year Per 1000 Causes. tion. of Age. Births. Causes. tion. of Age. Births. January.... 6,872 14.81 1,160 93.8 7,966 16.75 1,106 98.5 February... 6,126 14.61 1,008 89.9 6,723 13.11 1,054 91.8 March...... 7,462 16.08 1,231 93.4 7,077 14.88 1,126 90.3 Aptil.civ os 7,681 17.10 1,239 102.0 6,791 14.75 1,082 97.0 May. .....- 6,625 14.27 1,191 107.4 6,661 14.00 1,086 96.1 June. ...... 5,862 13.04 1,052 88.1 3,723 12.43 881 78.8 July... 505,818 12.54 1,201 105.6 6,209 13.05 1,072 96.3 August. .... 6,011 12.93 1,598 130.9 7,011 14.75 1,614 131.1 September. . 5,543 12.34 1,326 114.2 5,578 12.12 1,098 99.8 October..... 5,582 12.03 1,032 91.3 5,605 11.78 889 75.8 November. . 5,562 12.38 855 78.6 5,792 12.58 887 80.4 December... 7,049 15.19 973 81.3 6,605 14.01 923 79.1 Year... 76,193 13.93 13,866 98.2 77,801 13.88 12,818 93.1 SoME REFERENCES CONSULTED. V. Heine: Beobachtungen ueber Laehmungszustaende der unteren Extremitaete und derer Behandlung. Stuttgart, 1840. Spinale Kinder- laehmung, 1860. M. P. Jacobi: Pathology of Infantile Paralysis. Obstetrics, Vol. 7, p. 1, 1874. O. Medin: Kliniske og Epidemioliske Undersoeglser over der Akute Poliomyelit i Norge. Vidensk. Selsk. Skr. Christiana, 1909. Ed. Mueller: Die Spinale Kinderlaehmung, Berlin, 1910. Wickman: Acute Poliomyelitis (Heine-Medin’s Disease). Tr. Ma- loney. Jour. of Nerv. and Ment. Dis., Monograph Series No. 15, 1913. Warner: Die Heine-Medin Krankheit, Leipzig, Diss. Halle, 1913. Collective Investigation Committee: Report on the New York Epi- demic of 1917. Jour. of Nerv. and Ment. Dis., Monograph Series No. 6, 1910. Frost: Hyg. Lab. Bull. No. 90, Washington, D C. Frauenthal & Manning: A Manual of Infantile Paralysis, 1914. Lovett: The Treatment of Infantile Paralysis, Philadelphia, 1916. Harbitz & Scheel: Pathologish-anatomische Untersuchungen ueber Akute Poliomyelitis and Verwandter Krankheiten von der Epidemien in Norwegen, 1903-1906. Vidensk. Selsk. Skr. Christiana, 1907. Peabody, Draper and Dochez: Rockefeller Institute, New York, 1912. Landsteiner and Popper: Ztschr. {f. Immunitaetsforsch. 11, 1909. Leiner and Weisner: Wien, Klin. Wochschr. XXII, 1909. Landsteiner and Levaditi: Compt. Rend. Soc. Biol., LXII and LXVII. Flexner and Lewis: Jour. Amer. Med. Assoc., 1909 ; also 1910 and 1913. Flexner and Noguchi: Jour. Exp. Med., XVIII, 1913 and 1914. Netter: Bull. del’Acad. de Med., LXVI, 1914. Rosenow, Towne and Wheeler: Jour. Amer. Med. Assoc., LXVII, 1916. American Journal of 296 Regulations, Leaflets, Circulars and Bulletins Issued by the Department of Health. (REGULATIONS.) Regulation 1. Incubation period —The incubation period of the dis- ease and the quarantine period of children under sixteen (16) years of age who have been, but no longer are, exposed to infection shall be fourteen (14) days. Regulation 2. Quarantine—In all families where a case of Poliomyeli- tis has occurred, all the children under sixteen (16) years (except those who have had the disease), shall be quarantined in the home until two (2) weeks after the termination of the case by death, removal, or recovery. The patient whether at home or in a hospital shall be quarantined for six (6) weeks from the date of the onset of the disease. No case in a hospital shall be returned home until the quarantine is ended. Regulation 3. Placards—All premises where a case of Poliomyelitis occurs shall be placarded; the only exceptions being hotels and boarding houses, which shall not be placarded provided the patient is at once re- moved to the hospital, the room or rooms occupied by the patient immedi- ately renovated in accordance with the requirements of the Bureau of Pre- ventable Diseases, and no quarantined children remain on the premises. In private houses, one placard shall be affixed to the door entering the room the patient occupies. In apartment and tenement houses, one placard shall be affixed to the door of the apartment occupied by the patient. All such placards shall be dated and initialed by the representative of the Depart- ment who affixes the placards in accordance with the provisions of this Regulation and shall remain so affixed until the quarantine is terminated and the renovation completed. (As amended by the Board of Health, Sep- tember 26, 1916.) Regulation 4. Removal to Hospital —No case shall be left at home unless the following conditions are complied with: a. There must be a physician in daily attendance. b. The patient must have a special attendant who must obey the quarantine Regulations and must not do any housework, market- ing, or perform any household duties for other members of the family. He or she may, however, leave the house, provided the neces- sary precautions as to personal disinfection, etc., are observed, and contact with all children should be avoided. ¢. The patient and the attendant must have a room or rooms separate from the rooms of others in the family. d. All the windows of this room must be screened and all flies in the room killed. e. The family must have a separate toilet for its exclusive use. f. Quarantine Regulations must be strictly observed by the patient and the other children of the family, if any. When the disease occurs in the premises of families of food handlers, the employment of such person or persons at this occupation is forbidden, unless they 297 occupy entirely separate apartments for a period of two weeks after the removal, recovery, or death of the patient. The personal and bed linen of the patient must be properly disinfected and, after removal, recovery or death of the patient, com- plete renovation of the room or rooms occupied by the patient and atendant shall be required. Regulation 5. Visitors to Hospitals—Each case may be visited twice during its stay in the hospital, by a parent or guardian. If the child is criti- cally ill, the guardian or parent will be notified and will be permitted to visit daily, while child is dangerously ill. Information relative to condition is given out at the Information Desk in each hospital, or by telephone in response to telephone inquiry from the parent or guardian. Regulation 6. Certificates for children leaving the ciiy—The Depart- ment of Health of the City of New York does not require certificates of anyone leaving or entering the City. It issues certificates only as a con- venience and aid to persons leaving the City. None are issued to persons passing through the City. Such certificates state that the persons or family therein named have not resided in a house where a case of Poliomyelitis has occurred. The applicant must sign a request for the certificate. They are refused to per- sons who live in a house where a case of Infantile Paralysis has occurred, or who present symptoms of the said disease. The certificates are good only until midnight of the following day, except when issued on a Saturday or on the day preceding a holiday, when they are good until midnight of the second following day. Regulation 7. Return of cases of Poliomyelitis to New York City.— Cases of Poliomyelitis occurring in residents of New York City who are temporarily residing outside the City, and developing within two (2) weeks of the time of leaving the City, shall be permitted to return, provided: (a) a private conveyance (private car, private automobile, carriage or ambulance) is used, and (b) the patient goes direct to a hospital authorized by the Department of Health to care for cases of Poliomyelitis. Cases in which the onset of the disease occurs two weeks or more after leaving the City, may not return to New York City until eight weeks from the date of onset of the disease. But in special cases, where proper medi- cal, surgical and nursing care is not obtainable, patients may be brought back to the City in a private conveyance, provided they go directly to a private hospital authorized by the Department of Health to receive cases of Poliomyelitis. Regulation 8. Return of children who have been exposed to Polio- myelitis to New York City—Children under sixteen (16) outside of New York City who have been exposed to infection with Poliomyelitis within two weeks, may return to the City under the following conditions: a. They must come by private conveyance and must go direct to their homes. 298 b. Advance notice must be sent, and authorization obtained, by telephone, by the local Health Officer. Such notice must give the name and age of each child, together with the identified address, including the floor, and the latest date of exposure to infection, and must be followed immediately by a written notice. ¢. Such children shall be promptly visited at their homes by a representative of the Department of Health and instructed as to nature and duration of quarantine. They must not leave the premises until two weeks have elapsed from the date of last exposure to infec- tion. d. The premises shall not be placarded, but the children shall be visited at regular intervals, and should quarantine be violated the parents or guardians shall be summoned to Court and fined. ( PROCEDURES.) Duties of Inspectors—Cases reported by physicians, nurses, social workers and other citizens shall be visited at once by Inspector, whether such report requests removal of the case to a hospital or not. Attending physicians to the Department of Health hospitals, however, may admit cases direct without Inspectors’ visits. The janitor of the building in which a case of Poliomyelitis occurs, or his or her representative, shall be seen in every instance by the Inspector and notified that he or she will be held personally responsible by the De- partment of Health for failure to report any breach of the quarantine Regu- lations or the removal or defacement of the placards placed on the building. If the Inspector makes or confirms the diagnosis of Poliomyelitis, the Borough Office of the Department shall be notified. Such Borough Office shall, if removal of patient is recommended, summon an ambulance. In every case the Inspector shall leave with the person in charge or control of the patient a hospital admission slip or card, properly and fully filled out and signed. Where a case is permitted to remain at home, the Inspector shall give full instructions to the family. Cases of questionable diagnosis must be seen. at once, in consultation, with the Borough or Chief Diagnostician, and whenever required, a spinal puncture shall be made and a laboratory report submitted by the staff of the Research Laboratory. Cases with positive laboratory findings will be considered as Poliomyelitis, regardless of clinical signs. A full history must be recorded on a special card (Form 316-V) for each assignment covered by Inspectors. Duties of Nurses—Nurses shall visit every case reported, to instruct the family regarding quarantine, and every other family in the house: a. That there is a case of this disease in the house. b. That the other children of the family in which the disease has occurred shall be quarantined, and that, should they fail to ob- serve quarantine, that fact should be immediately reported to the Department of Health, when steps shall be taken to enforce quaran- tine by a summons to Court. 299 c. Regarding home cleanliness, personal hygiene, and danger of infection by flies, and other general measures which should be taken to prevent infection. d. To report at once to the Department any cases of suspicious illness of children, or any cases of Poliomyelitis, especially if there is no physician in attendance. A current history (Form 304-V) must be kept by the nurse for every case, giving dates of visits, action taken and date and mode of termination. Nurses must see the janitor or his or her representative on first visit and repeat the instructions given by the Inspector. Patients remaining at home, and families with quarantined children, shall be visited daily, or more often if necessary, by a nurse or patrolman for the purpose of ascertaining whether or not the Regulations governing the maintenance of quarantine are being complied with. After removal, recovery, or death of the patient, nurses shall issue renovation notices and make subsequent reinspections until the terms of such notices have been complied with. Duties of Sanitary Police—Sanitary police officers shall visit quaran- tined premises frequently, daily if necessary, to enforce quarantine of patient and other children in the family and to affix or replace placards. If quarantine Regulations are violated, they are authorized to serve a sum- mons upon the person responsible therefor. Duties of Ambulance Surgeons—All cases ordered removed to the hospital must be removed by the ambulance surgeon without question, with the following exceptions, in each of which the ambulance surgeon must first obtain telephone authorization from the Resident Physician of his hospital, to leave the case at home: a. When removal would endanger life of child (bulbar cases). b. When family physician can show that requirements will be met at once (or within 12 hours). Doubtful and mixed infection cases must be removed by themselves in a separate ambulance. In every case ambulance surgeons must leave a card with parents, giving name and address of hospital to which patient is taken. If inspector has not left admission slip, surgeon must make out same. Persons leaving New York State—Officers of the U. S. Public Health Service, stationed at transportation terminals, require the above certificates before they will permit children under fifteen (15) years of age, resident in New York City, traveling to points outside of the State of New York, to leave the City. The original applicant must again sign the certificate in the presence of the Federal Health Officer. Federal Health Officers do not require certificates of any adults. Persons Going to Points within New York State—Residents of New York City, adults or children, traveling to points within New York State, 300 who present certificates of good health from their family physicians, may also obtain the above certificates from the Department of Health. If no physician’s certificate of good health is presented, applicants will be examined by a physician and their freedom from symptoms of Poliomyelitis certified ; in this case, all children must be brought to the proper office of the Depart- ment. ( LEAFLET.) (Issued July 20, 1916.) INFANTILE PARALYSIS. (Poliomyelitis.) INFORMATION FOR THE PUBLIC. Infantile Paralysis (Poliomyelitis) is a catching disease. How it is spread is not yet definitely known. In most cases the disease is probably taken directly from a sick person, but it may be spread indirectly, through a third person who has been taking care of the patient, or through children who have been living in the same household. The early symptoms are usually fever, weakness, fretfulness or irrita- bility, and vomiting. There may or may not be acute pain at this time. Later, there is pain in the neck, back, arms or legs, with great weakness. If paralysis is to occur, it usually appears from the second to the fifth day after the sickness begins. Many cases do not go on to paralysis. The germ of the disease is present in discharges from the nose, throat and bowels of those ill with infantile paralysis, even in the cases that do not go on to paralysis. It may also be present in the nose and throat of healthy children from the same family. Do not let your children play with children who have just been sick or who have or recently have had colds, summer complaint, etc. For this reason children from a family in which there is a case of infantile paralysis are forbidden to leave their home. If you hear of their doing so, report it at once to the Department of Health. - Persons over 16 years of age, from families where there are cases of poliomyelitis, may continue at work unless their business has to do with the preparation or handling of food or drink for sale. If you hear of a case in your neighborhood and the house is not placarded, notify the Department of Health. How to Guard Against the Disease. In order to prevent the occurrence of this disease, parents should observe the following rules: Keep your house or apartment absolutely clean. Go over all woodwork daily with a damp cloth. 301 Sweep floors only after they have been sprinkled with sawdust, old tea-leaves, or bits of newspaper which have been thoroughly dampened. Never allow dry sweeping. Screen your windows against flies, and kill all flies in the house. Do not allow garbage to accumulate, and keep pail closely covered. Do not allow refuse of any kind to remain in your rooms. Kill all forms of vermin, such as bedbugs, roaches and body-lice. Pay special attention to bodily cleanliness. Give the children a bath every day and see that all clothing which comes into contact with the skin is clean. Keep your children by themselves as much as possible. Do not allow them to visit moving picture shows or other places where children may gather. Children should not be kept in the house; they should be out-of-doors as much as possible, but not in active contact with other children of the neighborhood. Do not take them on a street car, unless absolutely neces- sary, or shopping. Do not allow your children to be kissed. It is perfectly safe to let your children go to the parks and playgrounds if only two or three of them play together; they should not play in large groups, and you should not let them come into contact with children from other parts of the city. Remember that children need fresh air in the summer time, and outdoor life is one of the best ways to avoid disease. } If there is a public shower bath in a school in your vicinity, send the older children there every day for a shower bath. This is perfectly safe and will help keep them in good health. Give your children plain, wholesome food, including plenty of milk and vegetables. Keep the milk clean, covered and cold. Do not allow the milk or any other food to be exposed where flies may alight upon it. Wash well all food that is to be eaten raw. In Case of Sickness. Remember that during the hot weather children are apt to have stomach and bowel troubles. If your child is taken sick with loose movements of the bowels, or with vomiting, do not at once fear that it must be infantile paralysis; it may be simply digestive disturbance. Give the child a table- spoonful of castor oil and plenty of cool water to drink, and send for the doctor at once. If you cannot afford a doctor's services, telephone the Department of Health and one will be sent free of charge. 302 If a doctor or nurse from the Department of Health visits your home, give them all the information you can. They are sent to show you how to keep your children well. Do not give your children patent medicines or buy charms of any kind to ward off the disease. The best preventive is cleanliness and strict observ- ance of the rules that have been given. Although there is no specific cure for the disease, much can be done to reduce the amount of crippling caused by the paralysis. It is important to remember that this requires the services of a trained physician and the care of a competent nurse. Unless you can give these to your child, send word at once to the Department of Health, so that the patient may receive proper care in a well-equipped hospital. Of the children cared for in hospitals, only one-quarter as many died as of those treated at home. Give your child a fair chance and let the hospital doctors care for it. What the Health Department Will Do. If a case of infantile paralysis occurs in your home, your doctor must at once notify the Department of Health. An inspector will be sent to investigate. He will paste a sign on the door of your house and apartment warning all people not to enter. This sign must not be removed except by some one sent by the Department of Health. The inspector and nurse will tell you just what to do to protect yourself and the others in the family. Should you want any further information, write or telephone to the BUREAU oF PREVENTABLE DISEASES DeparT™MENT oF HEALTH, CITY oF NEW YORK 139 CENTRE STREET, NEW YORK. (LEAFLET.) (Issued July 20, 1916.) POLIOMYELITIS. INFORMATION FOR PHYSICIANS. Early Diagnosis. The attention of physicians is called to the necessity of an early diag- nosis of all cases of poliomyelitis. Early recognition and strict quarantine are the chief weapons against the disease. Reporting of Cases. All suspicious cases must be at once reported to the Depariment of Health by Telephone, to be followed within twenty-four hours by a written report. The ability of the Department of Health to limit the spread of the infection depends upon the immediate reporting of every suspicious case. 303 Age of Persons Affected. It should be remembered that this disease may occur at all ages, although the great majority of the cases are found in children between the ages of one and five years. Type of Disease. Peabody, Draper and Dochez, of the Rockefeller Institute, give the following classification of the disease: 1. The non-paralytic or so-called abortive cases. 2. The cerebral group, with spastic paralysis. 3. The bulbo-spinal group. Methods of Infection. The experiments of Landsteiner and Popper in Germany; Kling, Pet- terson and Wernstedt in Sweden, and of Flexner and Noguchi in this country, have proved that the disease is transmitted by the secretions of the nose and mouth, and the bowel discharges of an infected person. The infection is transmitted through the mouth, tonsils and nasal mucous mem- brane. Contacts and Carriers. It must be remembered that while the transmission of the disease from a patient to other members of the same family is not usual, transmission of the virus is common. Experience warrants the assumption that in addition to direct contact, the disease is spread by carriers, usually children, who are themselves immune but who harbor the infective material in their nasal or mouth secretions. Symptoms. Early symptoms to be regarded as suspicious are: Fever, vomiting, slight diarrhcea, listlessness, unusual fretfulness and drowsiness. Later, and more characteristic symptoms, are: The appearance of weakness in any extremity, skin and muscular sensitiveness, spinal pain, especially on flexion, apparent or real rigidity of the neck muscles, Kernig’s and Mac- Ewen’s signs. Course and Duration of Disease. Paralysis appears usually before the sixth day of the illness; it may occur as early as the first day. Other symptoms, except spinal and muscular pain and rigidity and skin sensitiveness, rarely persist. Non-Paralytic or So-Called Abortive Cases. Non-paralytic or so-called abortive cases are very frequent. In some epidemics they constitute from 25 to 50 per cent. of the diagnosed cases. The children have the early symptoms just mentioned, perhaps also the 304 muscular tenderness and spinal pain. If carefully observed it may be noticed that they develop a paralysis of one or more groups of muscles, but that instead of the paralysis continuing it all disappears within a few hours. It is obvious that the recognition of such cases is of extreme importance in controlling the spread of the disease. The diagnosis of such cases is greatly facilitated by an examination of cerebrospinal fluid obtained through lumbar puncture. General Care of Patient. Complete rest is of the utmost importance for either paralyzed or weak muscles for the first five or six weeks. Every effort must be taken to make this rest complete. The limb must not be allowed to dray on a paralyzed muscle. It should be supported by pillows or pads or bandages. There seems to be a greater tendency to atrophy if casts are used. A dropped foot may be supported by a sandbag or pillow ; small rolls placed under the knee often hold the leg in a more comfortable position. The weight of the clothing should be kept off the legs by hoops or other device If the head is somewhat retracted and the patient desires to lie on his back, he may sometimes be made more comfortable by a small pillow placed under the shoulders, allowing the head to fall back. The value of electricity for treatment in the first six weeks is very doubtful. In many instances it may do harm. Massage or passive movements should not be begun for at least five or six weeks and then should be used with great care. In cases that show a tendency to clear up rapidly, the child should be kept in bed for some time after the ability to use the muscles returns. It should never be encouraged to try to stand or to use the muscles otherwise until a consider- able time has passed. Period of Incubation and Duration of Disease. The incubation period has been officially set at two weeks. Non- immune, infected persons usually manifest symptoms of the disease in from five to ten days after exposure. The average period of incubation is seven days. The early symptoms, noted above, usually last from one to seven days. Quarantine of the patient will be maintained for a period of at least eight weeks. Prevention of Spread of Infection. 1. The children from an infected family will be confined to the house. (See ““ Quarantine.”) 2. During the continuance of an epidemic of poliomyelitis children should not be allowed to congregate in public places. 3. Fresh air outings or vacation camps are allowed, if kept under competent medical supervision, with an adequate physical examination of each child before enrollment and the exclusion of any child from an infected family. 305 4. Absolute cleanliness of all homes is essential; such cleanliness should include: (a) Screens in all windows. (b) Flies kept out of all rooms. (¢) Thorough cleanliness of all floors, woodwork, bedding and clothing. (d) Avoidance of dust (all sweepings should be done after the floors have been sprinkled with sawdust, bits of newspaper or tea leaves, all thoroughly moistened). (e) Garbage cans kept closely covered and washed out in hot soapsuds after they have been emptied. (f) No refuse, either of food or other waste, allowed to accumu- late. 5. Personal habits of cleanliness are essential; the hands should be washed before each meal, after each visit to the toilet, and before going to bed. Children should be warned about putting the fingers into the mouth or nostrils. : 6. When sneezing or coughing, a handkerchief should be held over the mouth. Kissing of children is also a dangerous practice and should be avoided. ProceEpure To BE ForLowep IN Eaca Cask. Isolation of Patient. 1. Complete isolation of the patient must be maintained until ter- minated by order of the Department of Health. 2. A separate room must be provided for the patient. No one must be allowed iu this room except the attending physician, the nurse and the representative of the Department of Health. Care of Patient’s Room and Surroundings. 3. (A) All rugs, carpets, draperies and unnecessary furniture must be removed before the patient is placed in the room. (B) All windows must be screened. (C) The sick room must be kept well aired at all times. (D) The woodwork must be wiped daily with damp cloths. Under no circumstances must the floor be swept when it is dry. It should be sprinkled with sawdust, bits of newspaper or tea leaves, all thoroughly moistened, and then carefully swept so that no dust may arise. (E) Toys and books used by the patient must be destroyed by burning after recovery or death. (F) Household pets must not be allowed in the room. Care of Bedding. 4. All cloths, bed linen and personal clothing which have come into contact in any way with the patient must immediately be immersed in a 306 five per cent. solution of carbolic acid and allowed to soak for three hours. They may then be removed from the room and must be boiled in water or soapsuds for fifteen minutes. Care of Discharges from Body. 5. A sufficient supply of gauze or clean linen or cotton cloth must be provided and all discharges from the nose and mouth of the patient received on these cloths. After use, they must be immediately burned or boiled. Bowel discharges and urine must be covered at once with chloride of lime and then disposed of by emptying into a water closet. Care of Utensils Used by Patient. 6. Plates, cups, glasses, knives, forks, spoons and other utensils used by the patient must be kept for his exclusive use and under no circumstances removed from the room or mixed with similar utensils used by other. They must be washed in the room in hot soapsuds and then rinsed in boiling water. After use, the soapsuds and water must be thrown into the water closet. Nurse. 7. A trained nurse or competent attendant must be in sole attendance upon the patient. She must not be allowed to mingle with the rest of the family but must be isolated with the patient. The hands of the nurse must be carefully washed in hot soapsuds after each contact with the patient and before eating. Termination of Case. 8. After the case has been ordered terminated by the Department of Health, the following procedure must be followed: (a) The entire body of the patient must be bathed and their hair washed with hot soapsuds. The patient should then be dressed in clean clothes (which have not been in the sick room during the illness) and removed from the room. (b) The nurse should also take a bath, wash her hair, and put on clean clothes before mingling with the family or other people. ActioN TAKEN BY THE DEPARTMENT OF HEALTH IN Eaci CASE. Placarding. Every house will be placarded without exception. In private houses one placard is placed on the street front (outside of house), and one placard is placed on the door entering the room patient is in. In tenements three placards are affixed, one on street door, one in entrance hall and one on door of apartment. All placards are dated. Quarantine. In all families where a case of poliomyelitis has occurred all other children under sixteen years except those who have had the disease are to 307 be quarantined in the home until two weeks after the termination of the case by death, removal or recovery. The patient, whether at home or in hospital, must be quarantined for eight weeks from onset of disease. Children under sixteen (16) years of age who have been, but no longer are, exposed to infection will be quarantined for fourteen days. Removal to Hospital. No case is to be left at home unless the following conditions are com- plied with: . (a) There must be a private physician in attendance regularly. (b) Person attending patient must obey quarantine rules; must not do any housework, marketing or leave premises. (¢) Patient and attendant must have separate room. (d) All windows of rooms used by patient must be screened. (e) The family must have a separate toilet for its exclusive use. (f) Quarantine regulations must be strictly observed by patient and other children. Deaths. In case of death prompt burial is required, the coffin must be sealed as in deaths from other contagious diseases, and the funeral must be strictly private. Church funerals are prohibited. Spinal Puncture. Physicians desiring the services of a consultant to perform lumbar puncture and report on the examination of spinal fluid should telephone to the Bureau of Laboratories, Department of Health, 1600 Stuyvesant. Physicians desiring further information should write to the BUREAU oF PREVENTABLE DISEASES DepartMENT OF HeaLTH, City OF NEW YORK 139 CExTRE STREET, NEW YORK CITY (Pracarbp.) (Issued July 15, 1916.) INFANTILE PARALYSIS (PoLromYELITIS). Infantile Paralysis is very prevalent in this part of the city. On some streets many children are ill. Keep your children off the streets as much as possible and be sure to keep them out of the houses on which the Board of Health has put a sign. This is a disease which babies and young children get; many of them die; and many who do not, become paralyzed for life. 308 Don’t let your children go to parties or picnics or outings. Don’t let them play with any children who have sickness at home. The daily papers will tell you in what houses the disease is. If your child is sick, send for your doctor at once, or send word to the Board of Health. Manhattan, Centre and Walker Streets. Tel. 6280 Franklin. The Bronx, Third Avenue and St. Paul's Place. Tel. 1975 Tremont. Brooklyn, Flatbush Avenue and Willoughby Street. Tel. 4720 Main. Queens, 374 Fulton Street, Jamaica. Tel. 1200 Jamaica. Richmond, 514-516 Bay Street, Stapleton. Tel. 440 Tompkinsville. (LEAFLET.) (Issued August 10, 1916.) WHAT EVERY MOTHER SHOULD KNOW ABOUT INFANTILE PARALYSIS Infantile Paralysis (also called Poliomyelitis) is a catching disease caused by a tiny germ. The disease occurs mostly in young children, but now and then attacks older persons. . It is not difficult to recognize typical cases of the disease. Here is a common picture: A child previously perfectly well complains of a little stomach trouble or diarrhoea. It is feverish, restless and irritable. In the morning the mother finds that the child cannot stand or perhaps that it cannot move its arms. Parents should be on the lookout for all cases of illness in their children. No matter how mild it is advisable to seek a doctor’s advice. Don’t be misled by patent medicine advertisements. The country is already being flooded by announcements of quacks who want to sell their stuff. None of their medicines are any good. Camphor will not do any good. See a doctor! The germ of the disease is present in discharges from the nose, throat and bowels of those ill with infantile paralysis, even in the cases that do not go on to paralysis. It may also be present in the nose and throat of healthy children from the same family. Do not let your children play with children who have just been sick or who have or recently have had colds, summer complaint, etc. For this reason children from a family in which there is a case of infantile paralysis are for- bidden to leave their home. If vou hear of their doing so, report it at once to the Department of Health. Much can be done to reduce the amount of crippling caused by the paralysis. Remember that this requires the services of a trained physician and the care of a competent nurse. Unless you can give these to your child, send word at once to the Department of Health, so that the patient may receive proper care in a well-equipped hospital. Of the children cared for in hospitals, only one-quarter as many die as of those treated at home. Give your child a fair chance and let the hospital doctors care for it. 309 WHAT THE HEALTH DEPARTMENT WILL Do. If a case of infantile paralysis occurs in your home, your doctor must at once notify the Department of Health. An inspector will be sent to investigate. He will paste a sign on the door of your house and apart- ment warning all people not to enter. This sign must not be removed except by some one sent by the Department of Health. The inspector and nurse will tell you just what to do to protect yourself and the others in the family. Should you want any further information write or telephone to the DEPARTMENT OF HEALTH 139 CENTRE STREET, NEW YORK Telephone 6280 Franklin [The other side of this leaflet bore the following :] INFANTILE PARALYSIS IS DANGEROUS! CLEAN UP AND KEEP CLEAN! keep their hands particularly clean. Be sure that each child has its own clean handkerchief. Keep your house unusually clean. Don’t allow a fly in it. Keep your garbage bucket clean and tightly covered. Have a general house-cleaning. Throw away all useless knick-knacks and rubbish. Use soap and water generously, and let nature kill the germs with sunshine and fresh air. Koa: your children clean. Bathe them frequently. See that they 310 Keep your children away from places where the disease exists. Don’t let your children play with groups of children. Don’t let them attend parties and festivals. Don’t take them to movies. Give them all the fresh air you can, but not on crowded streets, trolley-cars or boats. If you have a garden, keep the children there. Use the roof if you live in a house where there are no cases of the disease. Wash out your child’s mouth and nose frequently with Boracic Acid solution or plain boiled water with a little salt in it. Give your child cold boiled water (that has been kept covered) to drink. Be careful of diet. Give light, easily digested food. Let your child have plenty of rest. Put it to bed early in the evening. Keep your child’s bowels in good order. If you notice symptoms of fever, vomiting or tiredness, give a dose of Castor Oil. Put the child to bed in a room alone and CALL A DOCTOR. Keep all other children away until your child is well. COVER ALL FOOD THAT IS TO BE EATEN. (Press BULLETIN) From the nt of Health ae a OFFICIAL To the Editor: A very large part of the work of the Department of Health depends for its success on the co-operation of an enlightened public, and this, in turn, depends almost entirely on the amount of space accorded to health articles by the newspapers, If, when this reaches your office, your men are out on stories and you desire further information, we shall be glad to answer your inquiries over the telephone. Please ask for THE BUREAU OF PUBLIC HEALTH EDUCATION DEPARTMENT OF HEALTH «ase FRANKLIN 139 Centre Street, New York PRESS BULLETIN. 7. RELEASE Irrrnsdinly Issued (Date) ...... Scpk. 29... NEw Cases oF POLIOMYELITIS—SEPTEMBER 22, 1916. New Dropped as Total Total Cases. No Cases. Cases. Deaths. Deaths. Manhattan... cites sn 9 2,429 3 622 Brot... ln 3 587 2 137 BroollVIE © och se 5 4,470 5 1,105 Queens... ... 0000s 0vin 3 a 1,093 1 306 Richmond =... -..c.cu0. oo i 282 56 Total... iio 20 - 8,861 11 2,226 TotaliCases in Hospital... oni. 8 int Sieh nas Sie sare ss ala ans 2,823 Department: Blom pitals to sn cre th ey va a wh Rs Dat ie wine Sd 1,982 Other Clty Hospitals’ ii. .ualini oil on stale nie i aes Dean brs Ye ta os 449 Private Hospitals. ooo te ei sani bias Sores wll 352 Swinburne Island .... coi. siiniiivs inns van vs sis Sahn smean vs Sander Canes 40 CANCE es oy i tle eR Ts ATs Lert Sw we rs Bab et sea on fw an 460 311 Cases TERMINATED. Cases Cases Total Removed. at Home. Hospitals. to Date. Manhattan, ..o..obo iO ibaerite 5 32 28 979 BroaX BL. i can derbi oe ole 5 4 4 2 87 Brooklyn: ........o.oihscandiisnes 4 7 19 1,412 OUCH hy. cdr ins sine at en dd 2 4 7 187 Richmond... co i iris ai ans 5. a oi 143 Totals viie rinse ete, 18 47 56 2,808 Cert. Cert. Cert. Issued. Cert. Refused Issued. to Date. Refused. to Date. MantinttanC. .. 0 ni nn Ns 362 48,144 5 191 Bronx i Si Bh age 67 18,771 es 56 Brooklyn... hobd Sie te cited 343 59,490 ol 217 OHCENS it sv Shhd mts ss ain bie 68 13,988 nh 3 Richmond: cc id im tiie 5 cies 18 2,107 oi 5 Wotalen a. over, ve. 858 142,500 A 474 (Here followed an alphabetical list of the cases.) (CIRCULAR LETTER.) (Sent to all physicians in the city.) Office of the Commissioner. July 19, 1916. Dear Doctor: The present epidemic of poliomyelitis affords an unparalleled oppor- tunity for clinical study and observation. The Department of Health, through the co-operation of various hospitals which are treating a large number of cases of polimyelitis, has arranged a series of clinical lectures open only to physicians, to be conducted by men who have had an unusual opportunity to study this disease. You are cordially invited to attend any and all of these clinics, and the Department hopes that you will take advantage of this exceptional opportunity. These clinics are to be con- 312 ducted during the week commencing Monday, July 24, at the following hospitals: Willard Parker Hospital— ; - Dr. Philip Van Ingen and Associates. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Kingston Avenue Hospital— Dr. Louis Ager and Associates. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Mt. Sinai Hospital— Dr. Herman Schwarz. 4-5 P. M. Monday, Tuesday, Wednesday, Thursday and Friday. Bellevue Hospital— Dr. J. S. Ferguson (Isolation Pavilion, Ward 32). 4-5 P. M. Tuesday, Thursday and Saturday. Babies’ Hospital— Dr. Charles Gilmore Kerley. 4:30-5:30 P. M. Tuesday and Thursday. Swinburne Island— Dr. Frank Clark (Quarantine Station). 4-5 P. M. Thursday and Friday. Very truly yours, Haven EMErsoN, M.D, Commissioner. DEPARTMENT oF HEALTH Receiving a Little Patient suffering from Infantile Paralysis into one of the Department of Health Hospitals. ee Withdrawing Spinal Fluid by Means of Lumbar Puncture for Purposes of Diagnosis and for Relief of Symptoms. vie i Plaster Cast to Prevent Deform ing on a Putt ician Phys DEPARTMENT OF HEALTH GITY or New York An Interesting Group of Patients. All Had Eye Paralysis. 91g A View of one of the Wards for the Care of Patients ill with Infantile Paralysis. LIE 318 One of the Little Patients. Left Leg Paralyzed. Trained Masseuse Treating a Paralyzed Leg. 61¢ 320 Convalescent Patients Were Placed on the Porches of the Hospital Pavilions. DeparTMENT oF HEALTH The Wards were Sometimes Crowded—but the Cribs were Effectively Separated by Glass Partitions. 12¢ Another Crowded Ward (Queensboro Hospital). 323 lescent Ward. In the Conva Lawn Party of Children Ready to be Sent Home. Ze 325 Maps. In the following pages are shown reproductions of the Brooklyn pin maps (the originals approximately 5 by 7 feet), on which all the cases were shown by means of pins. In the maps here given the cases have been plotted according to the date of onset, a method which furnishes an accurate picture of the course of the epidemic. Onsets in Month of May, 1916. 18663—Beals—N. Y, 4 326 QWs ER Big Rs 3 nS vy Ar of "BROOKLYN SCALE 1000 FEET TO AN INCH Onsets in First 10 Days of June, 1916. 18665—Beals—N. Y. 327 Onsets in Week Ending June 17, 1916. 18666—Beals—N. Y. 328 «BROOKLYN S0A1E 1900 FELT 0 A eed Onsets in Week Ending June 24, 1916. 329 OB “ ROOKLYN SCALE 1000 FEET TO AN INCH Onsets in Week Ending July 1, 1916. The 330 is, HT 11,78, N AA 8) \ HRC \ LACORS ANKRERER Rath RRO Onsets in Week Ending July 8, 1916. 331 fl 1] fitli 75 id A SAR 3) Onsets in Week Ending July 15, 1916. 332 Cori Aad PEER ARSE Map or ROOKLYN SCALE 1000 FEET TO AN INCH vp Onsets in Week Ending July 22, 1916. TR LL pL WIRTH RRR rw ATR PE CCR A TR EE Er Ie Tr Pay ana. B.A 2 Y, Onsets in Week Ending July 29, 1916. 18698—Beals—N. Y, wi CANINE El Eads pom RL RE ERR Sk a | A Ba 334 ETT Onsets in Week Ending August 5, 1916. 18701—Beals—N. Y. LR eH Tvs 335 18702—Beals—N. Y. Onsets in Week Ending August 12, 1916. 336 Onsets in Week Ending August 19, 1916. 18711—Beals—N. Y. Onsets in Week of August 26, 1916. 18712—Beals—N. Y, 338 AY” Onsets in Week Ending September 2, 1916. 18713—Beals—N. Y. 339 po ny o MAP * BROOKLYN SCALE 1000 reer TO AN INCH Onsets in Week Ending September 9, 1916. 18714—Beals—N. Y. 340 % SWE RSE Y MA OF 5 is "BROOKLYN SCALE 1000 FEET TO AN INCH Onsets in Week Ending September 16, 1916. 18715—Beals—N. Y. JG / RPA pr MAP OF The Borough of BROO KLYN Distribution of Brooklyn Cases in 1916 Epidemic. -TAh -—.. EEE TE A ES SFT J PRE a Distribution of Cases in 1916 Epidemic in Manhattan. ‘ 60—Beals—N. Y. A SYS PRICE 29° Xp OF THE BOROUGH OF ibaltitita, Lonny NEW QUICK REFERENCE: ‘STREET INDEXED MAP ALE BOROUGHS FURNISHED ON THIS SOALE EXPLANATION Fivvated Lins © ng i el Sn a1 4 mney aa J : E E oe tates be sas ALY LAN BE Cr ————————r nt % ‘ Distribution of Cases in 1916 Epidemic in Queens. ENE Gl ei ET TTT a The Bronx. mn 1c demi a 43] ) — 2) — a 8 © 3 — © a 3 % = fe] - 2 = TIEN ETE “kN i Ee RTT CEFY AT 5 partes 7] Hod Lo 4 --:E - BELCHER * HYDE 4 rd LV rE ® or Sublished by 000 u | eed ++» BROOKLYN --- V / IE es 3 SE Fa / ~ =f py: KREISCHEAVILLE - = Fo i WILLOW BEG H Ne esdon EXPLANATORY Pakio, Bowens Distribution of Cases in 1916 Epidemic in Borough of Richmond. Sa ot fh moa uk £7 A Sof ET - pr » ue geese. AR = oa Trea 351 TasLe IL Epidemic of Poliomyelitis Prior to 1916.* Year. Season. Place. Topography and Distribution. Cases Death Rate. Evidence of Contact Infection. Age Incidence. Special Annotation. Reference. Bgl... “Summer... oe. Feliciona, Lo., U.S. A... co 8. Country district, radius of four miles......... 10 0 0 Inder 2 Years OF GEE. «vx v iets sunvnsn or tamlens on pa Th singles cates se ite For nm apte vs baw care Colmer—Am. J. Med. Sc., 1843, V., 248. 1843... . ve Summer... - os England wh nn th hr ARERR, von in 4 Rural districts. . «rv. cs vis vive ve isinte isis enn « ? RARER EA SRT SPC a gi wae All young children. . .. 0, cosine cons vous FEW SPOradic CASE Sis or « viv win A uv o sep vv amine Nude ne McCormac—Lancet, 1842-3, II, 301. 1868.7... June=Aug. 5 id NOTWRY . Jy so oa es sasifs Tiara satan ests « One country district. . ..... vive Cate ie 14 36% 0 86% young Children, 149, adil. . 2. iv cai Tite ins vvens vom saisians adam ns ss Cavnees ress ras ione 1871-1875. Over 4 years....... Philadelphia, Pa., UcSEALL fer cues £15 SRNR hg AN PEI, mre vn TA 86 ? 0 Alfyoung children.......: aiviviiivis SPOIagiC CASES. 7 crv erewes suns sr ass sie Fares vv vee® tSinkler—Boston, M. & S. J., 1898, Nov. 23, 188%. ol sens uly. eae lenin ea le Sian k Umea, Sweden. .. is csins cris vars sai vis Tarts ahs siiveny 18 0 0 Allyoung CHEE, » oo cir ves ais 0 vias + aie on BEA + ¥ SRR Bh Ahr 2 AH hw © Sle Bergenholt—Reference in Medin Hygeia, 1890, ir, 657. 1883. 0. civ. June mi A Arenzano, tally ..o0 ve danger sv Small village 5 40% 0 All young childrens... ie ane te isms Sia narad nasa fos stares ris fails os ssmnnrtss ons s duos Buchelli—I1 Policlin, 1897, IV, 249. 1886........ July-Sept sv ales we Mendal, Norway.......cici. vsinninss Country district... vv uviaurssrunsnneses 9 22% 0 ST IS iy Been ie we mle ney «asin oe ei sevrenns Was also prevalent in six other districts—no details. ..... Harbitz—]. Am. M. Assn., 1912, LIX, 782. First cases were described in 1820; a previous epidemic Leegard—Neurol. Centbl., 1890, IX, 760. occurred In 1868 (Ch. Bull.) ... .. ci nica vavssasas Oxholm—Beretning om “Sundhedstilstanden og medicinalfor- holdene. Norge, 1886, 10. Tidsskrf. Prak. Med. 1887, Vir, 193 1886........ June-July..... +... Ste. Foye I'Argentiere, France............ Village of 1,500 people..v......., AE 13 31 Two cases in one family. Allyoung CIIAIEN. . i. 0 ivi ca wis gis alae 4 alae ale sais ale aie AA A FR Cay Cn eA Cordier—Lyon Med., 1888, LVI, 188%... ..... May-Nov......... Stockholm, Sweden... .... ie ove TSCItY «fos dvs aniuia v's snies viainisinrs yi 44 7 Two cases in one family. All young children. Sporadic cases to the number of 46 followed 1888-94. Medi a, Med. Cong., hor 11, Abth, VI, 37. » ygeia, 1888... ..... SUMMer........scv. Ammeberg, Sweden... ... cece corse 14 8% Fk erin Sus sn was worn ae ee tise «+r Coin AE >a aE SRE HE wr A We ete Ln wail} 4 SR EY Eas let x rw Yel RR The State Med, Inst. of Sweden, Report; Investigations on Epi. demic Infantile Paralysis, 1912. 3889. ....... June-July..... +++. Thuringia, Germany...... He Rrra 3 0 0 I a IRR ra TR ge IN RL RR TRICE Little groups of cases occurred elsewhere, for instance in Briegleb—Ueber die Frage der infektiosen Natur der Ac. Polio., Frankfurt and in Kiel 1 5 1893........ Summer... ...545 St. Girons (near), France................ 5 0 0 All young children... iin ia., Gaz. des. Hopit., 1895, LXVIII, 1036. 1898... Ney ha Boston, Mass., U.S. A... .coviici vans 26 ? rate tne tees Ral Bas wea Al young children... ...... ive vives tPutnam—Boston M. & 8. J., 1893, CXXIX, 509. 1804. ....... Aug.-Sept......... North Adams, Mass., U. S. A... ........ 10 0 0 All.young children... occ cides serves Brackett—Trans. Am. Ortho. Ass., XI, 132. 1894, _...... July-Oct..iouii. 0 Part of Vermont, U. S. A....vvnnrvunnons Comty district with 26,000 population. ox 132 8% Two cases inone family................. 67% under 6 years of age................ Animals affected with paralytic disease—horses, dogs, Caverley—]. A. M. A., 1896, XXVI, 1. OWE el vrs soir futni ir ss hr + Pain sy wn Cra vn Caverley—Med. Rec., 1894, XLVI, 673. Caverley—YVYale Med. J., 1894, 951, 1. Macphail—Med. News 1894, LXV, 619. 1895. nv - Aug-~Sept......... Stockholm, Sweden... ...... cc couneins CHV. or so tn wns wis an oles again din 4 S04 it wx Suan inte 21 0 Two cases in one family................. Allyoung children... ..... Wh... .... 4% Infantile cholera was ‘‘very severe’ at the time........ Medin—Arch. des Med. d'Inf., 1, 259, 321. 1895........ May-Sept Revecca, Italy. ..... Crowded section of large city (Genoa)... .. 17 0 Two cases in one family; three in another... All YOUN CHIIION cL ovis ivr tree Ua venniosnnss tases sane suoss visss nion sens sin suse sess Buchelli—I1 Policlin, 1897, IV, 249. 189%: cr ives June-July Montespertoli, Italy Rural COMMUNE. . . 50 a 2 ies aus es amine sieteis as 7 0 All young CHIEN. «is. 2 5 «Co si ss sat alee sean dn erties winnie slo cin 3 aces 40s + #406 2700 4 cialis sk oe wrle Pieraccini—Lo Sperimentale, 1895, Anno “ 0 27,521. 1805... ..4, March-April....... Port Lincoln, Australia............ 0. Village and surrounding country............. 14 0 Two cases in each of two families....... vv AI YOUNE CHITIN. «voir tide cits « Palio vigis + nies SDE Ss 0 Lui i wt wa aa Hg ae Bondurant—Med. News, 1900, 77, 1896... Sumner... ... vc.» San Francisco, Calif., U.S. A............ BUY. «ans ra pie ve sae sive wy suis bine nte 7 0 0 All young children A previous case occurred in Eureka in 1875 Sherman—Occidental M. Times, oor XI, 445. 6 Cherryfield, Me, U. 8. Av... vivre Village. . .o. i ovciionis aves arts sietncioisies en 7 1% Two cases in one family................. All young children Taylor—Phil. M. J., 1898, 1, 208. Much Hadham, England. ............... Village i in Hertfordshire... ... cus vrrai-eionnsie 7 LL ER A we Ren RE I Wa BEE All young children. . Bestoup rae, Clin, Soc., 1897, XXX, 143. New York City, N. Y., U.S. A. ....."..s CIey. ce ate rains sities cine nine slate ite 12 0 0 All young children. . Cases all came to a c! . half mile radius. weve crores uen London, England... . cu co iongnsvde i 11 as th By Us Caan A A a rE AE Nn AAA 1 a the GA gan te at&t H SR R k wy AR Buzzard—Lancet, 1898, II, 366. Conegliano, Italy. . i * 9 0 0 Al young ehllAren. .. Lok. . oii re on EE aie monn so oi a ateie ae + Fabris—LaPediat, 1901, 1X, 180. Conegliano, Italy. 13 0 0 AllLyoung children... . voi... Liana Sporadic cases..... Fabris—La Pediat, 1901, Ix 180. Royerstord, Pa., U. 22 ? 0 A young CHIIGIEN cou i ccs sv inamait's wis op ins a 'sltits #it nin sales Ele pie'sis #is SAAT Ire Sn sr wine vn udiadns + 050 . tJ. Nerv. & Ment. Dis., 1899, XXII, 210. NOIWayY.. deers’ vu 3 88D rae ea x Hs i Cal va ow uAllwoung children... ...5.... 0 conn. ‘“Cerebro-Spinal Meningitis also very prevalent’ Harbitz—]J. A. M. A., "1912, LIX, 782. Praort. Germany 15 0 0 All youngchildren............. uous Cases saipe 1 a clinic; 11 others had appeared during Auerbach—]. fiir Kinder, 1899, L, 41. PIEVIOUS FIVE WOATS, oicaes « «ssa vnn ssn sums snkrnnss 1898........ July-Sept....... 0 Vienna, Austria. .o, 000 Sood dd ide 42 0 0 Lr a el A Sc, I I EE i SR BU Zappert—]. fur Kinder, 1901, LIII, 125. 1898........ June-Sept. ........ Kiel, Germany rio. itu. wisn « svisng 4 0 0 BI OUNE CIIATOI hs + iuicn se 15 14 sss vn nis s soains aims in eae ahaa x a ae a eatonlhn 4 + vol gh cn wee as on Von Pleuss Ueber gehduftes Vorkommen spinaler Kinderlihmung. 1899...... 7 Bept=Oct.... uuu Valley of Arno, Italy. ........ cc. co'en Country distiret............... 5 0 0 AI young Children tv fe itin, (35: oronins warraiassiniele ouidie anion seen sleln fias'ss ss asinn ino « £s0n 4x0 Ey Simonini—Graz. degli osp. e delle clinichi, 1899, XX, 456. 1899... ..4- July=Oet.... co. Poughkeepsie, N. Y., U.S. A.....oonvnn Town and surrounding country. . 30 4% Two cases in one family................. YOUN CIIIALRI. sss free ronens sv ains anne Ses aiad es siamese nleinsinitsssianses ovens vie ss snaoe sins Mackenzie-Med. Rec'd, 1902, LXII, 528. 1899... vi. Summer... .v. «>. Stockholm, Sweden... cov ve cosines CY, oo vite stem a vis «4 = vainiels stair ainieun sisimintete 54 BO oe el At sneer rae nin ale na Sale ihr Trt on EAA Oh LCR ATE a EAE a a Ce naw a x nly CH State Med. Inst. of Sweden, Report; Investigations on Epidemic : Infantile Paralysis, 1912. 1899... June-Aug.......... Le Grand, Calif., U.S. A. hi. es Village of 42 inhabitants. .......... ey daisy 4 0 Two cases in one family................. Young children... voy oi vis vnees ar a mallee tei A et St es SRA A a 4 4k AA Newmark-Med. News, 1899, LXXIV, 101. 1899. ....... July-Nov... Bratsburg, NOIWay.. .L.. assess sas «vans Country Qistrict. . . . 0s cate vis de sasinine ution es 64 3% Two cases in one family and four in another Young children.............c.ovvuunvnnn Diarrhoea Epidemic. ose arent vrais er ewe Fran e Leegard—Norsk Mag. f. Laegevidensk, 1901, LXII, 377. 1899... 5 June-July Thuringia, Germany. .... a... a .:. oo Country district... . i. sends snprnnnnsinesss 5 BE re ei are ee thw a 0 xy AS a yh 0 Te REET NR SAR aie SITE TL A STS SIRE a ER YIN SE Briegleh~Ueher de Frage der infektiosen Nature der Ac. Polio.. 1890. June-Sept....... «» . Gloucester, Mass,, U.S, A...vovis cove ven Village... oaivivsunniniinsss dain vases vis ith 32 3 5.» Givin 4 ns ora hyn Sr AH SI YOURE CHAIR. see f nie Tennis ss ain's meno Thy aw Binsiaien vasa sesnas vid vs nase senate ssn sesionssssne Painter—Boston, M. & S. J., CXLVII, 633. May-June......... San Francisco, Calif., U. Sos. cna. CY. + svnsinne nsosnensns tresses sens “:¥e 55 0 Fre Caine es ra a 3 Ee ee Young children......0 0c. calleits «vu tov Son In 1898 four cases were reported in Merced Co......... Woods—Occidental Med. Times, XVII, 77 ; : : Newmark—Med. News, 1899. Summer. ..... c. 4 San Francisco, Calif., U.S. A............ CIV ss se ede Svs va Ea dunn sinin's sleisieingion sus 4 0 Young children..........v... 0h aes Woods—Occidental Med. Times, XVII, 77. Mar~-Sept......... Parma, Maly... vers as cna as vriscns CHV « coos s insta sans san venus Foire re 26 0 Young children. Larenzelli—La Pediat., 1904, 428. Summer... .. i ven Gothenberg, Sweden. .........co0ivinnen CIE. 0 Cit dir vs teins rte isie as ¥ifaSle.cit 20 BS nm tisaerr aaa ates ee «vias Wei Te eee Ce The State Med. Inst. of Sweden—Report: Investigations on > : Epidemic Infantile Paralysis, 1912. Summer.........«" Norway. . Disseminated over country. ................ 18 33% Young children Harbitz and J. A. M, Ass., 1907, XLIX, 1420. Summer Norway. . Disseminated over country . 61 20% Young children Scheele and J. A. M. Ass., 1907, XLIX, 1420. Summer. . Sidney, Australi City. . 49 0 Young children Netter—Bull. d. Acad. d. Med., 1910, LXIII, 458. Mar.—April. . Brisbane, Australi 3 8 . Town. 108 4% 109% were 10-15; the rest younger....... Ham. Aust. Med. Gaz., 1905, XXIV, 193 Mar.-April. ....... Queanbergen, Australia. ................ Town 6 ? Young children. ..i.c ui... ni Swern {Blackhall Med. Gaz., 1904, XXIII, 347. July-Sept......... Norway....... 0 0c ciate iin Disseminated over country. ........ al 719 15% Mostly young children. ................. Many abortive type Cases... ....rcarsccnvtamns rude os Geirsvold—Norsk. Mag. f. Laegevidensk, 1905, LXVI, 1280. July-Sept...... «trois OWEN: ; Fei aie tes nse arr avanae as Disseminated over country. .......... saa 1,030 17% Mostly young-children. .... iio... ov vuay % of cases in towns—25% of Sweden's population is Naunestadt—Norsk. Mag. f. Laegevidensk, 1906, LXVII, 409, rban. 1906. Harbitz—State Med. Inst. of Sweden Report; Investigations on Epidemic Infantile Paralysis, 1912. Re Tidesurife for Norse Laegeforenning, 1905, No. 17, - , 601. 1905... +! x SSUImer. re. ‘7 ve DAVEE SGCIINRNY. Pd tin tiv vv + Crags ov smaonis Sar Sle sd sna tae d ss vawea orden 197 Cy RA a A ITS ek vk A ai Ga sal wna Tes a sh rie de ie oes 4 rae EP RAE ie die 4 na eis SIE Ro A as ARR $y Uffenheimer—Muench. Med. Woch., 1903, LX, 2833. 1905... wu. Summer... ......» St. Mary's, Canadas. 7. ans Stars BOWIE. J yoo: on adie naw vunieiis wie nial A 17 6% Three instances of two cases in a family Fifteen under 10 years. 1905..... “es Summer...’ ...s¢f THNoIS, U.S. A... .orcuniirsvTossnss dress ly district of State... . faut . oe 8 DT a ree se A a aa Tas Pet aay aA A ale a ae Snr leh vale Aan RA ie yr Cane er TTA SS eo FOYT tNorbury (?). 1906... Summer..... Fos re SWRI cui ieiris + ss snr mrnies sn Fert RE ae ye as ats rie es wie as en ae : 429 BOT, i = Bas cinnsln es Wein vases sms ou paar Fifteen cases and three deaths at St. Michaels and Unkaleet, in 1912. 1906..... Summer..... wrt AINOTWAN cnt cr nn cris saat & Siarnins'ss vineininie Disseminated over country. ............ ao 466 10% Sa irene Than wae en or eure ues «Mostly young children... .. on sins lal a AA NE a a ee es ale Siaanie ait sewn 4 a Saar sr Naunestadt—Norsk. Mag. f. Laeg., 1906, LXXVII, 409. Harbitz—15 Int. Cong. Hyg. & Demog., 1912, I, pt. 2, 577. Platou—Tidsskrift for Norse Lacgeforenning, 1905, No. 17. 1907... .... = Summer....:. weve dive Oak, Ra Ud. Si Bu. I cad sr ins den Tok asin san 2 0es sn + + sutsis etnies fen ne. 16 ? tEfird—Trans. Florida State Ass., XXV, 601, 1908. 1907........ Summer..... rr vais INOINWEAY stiso ov To 5 naigors 4 vans Ged Viera Disseminated over COUNLIY . odds an anenness 204 15% Harbitz—]J. Am. Ass., 1912, LIX, 782. *Most of the material covering epidemics prior to 1907 was taken from a report by Holt and Bartlett in the Am. J. of Med. Sc., May, 1908. tQuoted by Frauenthal and Manning in their book ‘Infantile Paralysis.” isis RN TET TEE : 1 KE: Ls 353 TaBLe I—Continued. Year Season. Place. Topography and Distribution. Cases. Death Rate. Evidence of Contact Infection. Age Incidence. Special Annotation. Reference. 1907... on» Summer..... Pr New York City, N. V., U.S. A.....500n 0 Clty BRB hones ave fame vein 2,500 Si, Sa a ea we 5 a + He A Ay TLD a VIR J dete VL MIR TE pt mn ROBB 1 ER IE TER Ta Era Report on the New York epidemic of 1907 by the Collective Investigation Committe, Nervous and Mental Diseases, Monograph Series No. 6, 1910, Massachusetts, U.S. A... oa ives Disseminated over State............00i0aun. 234 5% Mostly infants. ..... None of seven cases under 1 year were exclusively least fed. Lovett—Mass. St. B. of Health, 1908, 756. Oceana Co., Mich, U. 8, A... icinsrissns i svssnsansntiassssiss ss eivales sieves peels ee ‘ 20 5% 60% under 10 years Cases reported in other parts of State. Paralytic diseases Griffin—] Mich. s. Med. Soc., 1908, VII, 49. 2 of chickens epidemic. Pennsylvania, U. S. A... vneisnn vv ous City of Philadelphia and town of Dubois. .... 143 BO i Tina ane Si sees Sania CIT CI, 5s os ss 5 EE nine aun wie ela FE Siw Te wig as 5% Ia ew iubiey + as hots ene Te om ets 3 mid ok 4a 0 nen McCombs—Arch. Pediat., 1908, XXV, 37. Free—]. Nerv. & Ment. Dis. ., 1908, XXXV, 259. Paterson, N. J., U.S. A Small city—other cases disseminated over State 24 OO ET + Vie bv vs ti vas sie viv sap wy Fr Young children. ......... coo. 0a aed Most of cases seen in Clinic after acute stage. .......... Bowden—]J. Med. Soc., N. Jersey, 1908, V, 28 . SWERH., . yw. seve vans satin tev ren rs mains tase sin nnls ss salads siyiy ute’ isle ieiole loots iets 467 LE sn RT UTR a Re RRC pT ar ee RE Re Be UE CO ER TER A ROR RE Ye) Dixon & Karsner—Am. J. Dis. of Child, 1911, ir, 221. Pennsylvania, " Four N. W. counties. . ..ce..: +» sane smear 200 SS IIE Te vee ene tr Pram eat vara saan Small outbreak Adams Co. in 1908; 1909 New York City, 'N. Y. U.S.A (See separate table for New York City and State, appended.) 0% sporadic cases only. WRHRIL «0 . civvnn rnvvivins wr vd walle sin rat ky san aa wate ns ss via sls sininieis ee isle sis atic sissy 1 10% Heidelberg, Germany. ..........c0c0unns TOW. «vice vs vs nv nus sivins sintoin sores ors see 36 AS RE TR Ee REA a per All young children except two adults...... Cases in other partsof Germany. .........covuivunnnnnn HoRmane-Quoted by Netter, Bul. d. I'Acad. de. Med., 10, LXIII Jowa, U. 8. Ac. cv ines Beer nnn Kassuth Co... cairo 5 daidenninn Sins viele By 12 Cy Aisne x iain + ¥en ly Oh Sr anes AN Under 12° WETS, Cos +05. 0 cunts sites sine 5 Tite es =v sala wiaiete dns Pree aa abe ak + ae wd arn Bierring—Interstate M. J., 1912, XIX, 35. EDRIand. oo s ve csssininn sn on Poses vires Essex COURLY. . ..- 5s copia vue om ute vas fisteteies 8 a ON i eC a RRA ce a ar sled Kat Sn SRE EE TT hai we tS etl i nd tk st ae A re Lye TN arenas 8 xe 5 Amv TRAN Treves—Brain, 1909, XXXII, 285. 1908---..... Principally Summer: NOTWARY. 15.5 tunis sv viv snns sonia snail. Small local epidemics and sporadic cases...... 59 BO airs Co a ind sen va a NG ye Ca ed ER a AN in Cn x x SN ete th aie are a vs SA Harbitz, 1912—]J. A. M. Ass, 1912, LIX, 782 1908... July—Sept.......... Flint, Mich., SA TO ueveral local epidemics in other parts 30 BE 5 aii Bra vas vn smite wn 3 we a ye 37% under 10 vears of age: 20% adults oy vant is Cr Ti i ear vs a ana Wi oe re a Manwaring—]J. Mich. St Med. Soc., 1909, VIII, 161. of the State. 1908. .....-: Summel TL en RUBBIO., i Cs Fon vies sian dame ae Yise Of 500 people... vcore iesvinnineisse 49 a i RN Pg. AS LR NER RI et CR a TER Sl Ca RE UE pa ERR A Schwarz—St. Petersburg, Med. Woch., 1909, XXXIV, 21. 1908... ...: SUMMEeT. oo ov «vn Whittemore, Iowa, U. 8: A. ..uuvuucnn iii DOW otis s vinsage vies alas v eluiultiafs sities tv's 10 a ir EL AREER Young children... i... TE eerste sass s Fons dats sony +o Pasainn viele es « wines in McCreery—Iowa M. J., 1910, XVI, 519. 1908... Soames (late)....... Minnesota, U.S. A... ..:. 5: sian suianes Cons and four villages. sn V5 ae a eiaee + eaten + 150 9%, Five cases in family ‘of six persons; three “Mostly Children... o.oo ioe sire Tin ve vies sinmntan cus rain Pais srisinin x's. slrieitatiags » + »/osalonib mien Hamilton—]. Minn. M. Ass. and N. W. Lancet, 1910, XXX, 2. cases in family of five persons; three cases in family of four persons (two instances). i 1908... Autumn........::. Melbourne, Australia. ..........o00uuunn CHEV «cov vain ass Valen ica uin sale + =n wishes ww feismelvivic 135 RR NR ERR rT AT PIE Mostly children : Stephen—Intercol. Med. J. of Austral. 1903: XIII, 573. $908.:...... July—Oct.. Vienna and Lower AUSEHa. .......ovnnr. Drvciinated OVEr COUNLIV. . «ous svisiis» 266 119, Occasional secondary case . Young children . Zappert—Wien. med. Woch., 1909, LLY, 2683. 1908... = SUMMEr. cess + saws Wisconsin U.S. A. eiciecsscrrsiavisr ins In one small city (Eau Claire) other small local 408 15% 29 cases known to have been exposed. .... Youngichildren. ..... oc... 2 somes avn Estimated number of cases in State 1,000. In 1907 22 Manning—Wisconsin M. J., "1909, VII, 611, and Woman's M. J epidemics and ‘‘scattering™......... eee cases were reported in Trempeleau County. In 1909 1910, XX, 118. 18 cases at Richland Center.............. Srey Cases and Deaths Since Reported to the Wisccnsin State Correspondence with State Board of Health of Wisconsin, Board of Health. ases Deaths 1900.0. vous cons ara a ses ? ? 1910. 00. wh Yr . vive 135 39 Olea ad rn de se 70 33 BOI en rs Cs ae ah 56 27 BOIS cree cnse vn stuns nines v 26 | IO... Cd ever es 31 15 : B91... cs cer are ee 14 9 BORG... or Crees Ure ey 473 76 1908. .....+. SUMIMCE cots. 5505 Massachusetts, U.S. A...... ceva snenase Disseminated over State.......... Conn sininieee 136 6% Two or three instances of two cases in same 90% under 10 years. ................... In 69 families of single cases there were 166 children, but Lovett & Fraerson: Monthly Bul., Mass. St. Bd. of Health, 1909, amily... ive len ae eh only two later cases. Rare in districts visited by epi- n. s. IV, 139, 146. demic of 1907. : 1908... «i. June Sent sSea ier tn Salem. Va, U.S A. ..ociv.. coiaviony 0 FOWL, 4 viv anv untae Sue's ela lviedeeiss « 25 0: NN rms sete she ves the Ta a Er ae Young children... . cv x o.o0uis ar sinnni sins Saislrwainie san tiols Wiley & Darden, J. Am. M. Ass., 1909, LII, 617. 1909.5... Aug—-Oct....e.. ut Minnesota; U. S. A. - cic Jovi vesivnncnnrinine In cities, villages and rural districts......... 600 S050 rn ... Over 80% under 10 years of ag . 238 of the cases were in St. Paul and 40 in Hamilton & Hill—]J. Minn. M. Ass., 1910, XXX, 2, 5. 3900... AL i rr or Nebraska, JJ 8S. A. «cu cvsit wera ss anions Country and villages. ...<. 0... oid on 1,037 13% Seventeen same 85% were under 10 years................ In 41 families comprising 156 children 86 were affected, Armstrong, 1910, XXII, 486. family. . coe eer Sais nbn 55% of all cases occurred in two countries comprising or Anderson, 1910, Anderson Pediatrics, 1910, XXII, 543, Western 31,000 POPUIRHON. .... 3c es «cores iwi fe vt Cain ress M. Rev, 1910, XV, 391. McClonahan—J. Am. M. Ass,, 1910, LV, 1160. 1909... ....- Summer... 0s Hesse-Nassau, Germany................. Country district... oc... avvues ahalesasnete vin 130 QC Rca tar A eh Se ESCs oh A Mostly young children.......... Coie sir Tee Sporadic cases all over Germany. ..........c0vvunnaans Miiller—Miinch. Med. Woch., 1909, LVI, 2460. | 3 . as Romer—Die epidem. Kinderlah, Berlin, 1911. | 1909... nus Summer. ....c.c00- Rhenish Westphalia, Germany. .......... Country district. .... Jovi vsine o fu vinisnielamisivie 500 LAR Nh ROE Lo ON A She Mostly young children. ................. Great mortality at same time among chickens.......... Reckzeh-—Med. Klinik, No. 45, 1909, V. 1704. Krause—Deutch Med. Woch., 1909, XXXV, 1825. Potpeschnigg—Arch. f. Kinder, 1910, LIV, p. 343. 1909... ....- Aug.-Sept......... Holland. voor. ios iota smeiannis + v smn Leyden and Warnsweld (towns). .... egies 38 11% Mostly young children. ................. Also revalent in Belguim. Sporadic cases followed in Neto et. Mm: de la Soc. Med. des Hop. de Paris, 1909. | YOO 1003... ct nie aes ava sa aa aa XX , 554, 746. | 1909. ..v.... Summer and Winter Styria, Austria...........cocivniivinvan Portion (mostly rural) of central Austria. .... 600 14% Mostly young children. ................. Began in autumn of 1908. Considerable number of Reckzeh—Med. Klinik, No. 45, 1909, V. 1704. children at the breast were affected. Also many cases Krause—Deutch Med. Woch., 1909, XXXV, 1825. : , inupperand lower Austria. . ..........c.ccouniennnnn Potpeschnigg—Arch. f Kinder, 1910, LIV, 343. 1909..." Summer. ....«: « ai Paris (and environs), France............. Oty Tha Ha orn salen ae ee ia . 41 10% Mostly under 1Q years, .... ovis avis 13 cases were reported in France (1888) by Cordier. ..... Netter— Bull. d. I’Acad. d. Med., 1910, LXIII, 458. £ Lovett and others—Bull. Mass. St. Bd. of Health, 1910, n.s. V, 241. | 19098, vi. viv SUMMEY....sersase Massachusetts, U. S.A... ov. Jolin vaidiens Generally distributed over State............. 923 8% 87% under 10 years..... .....cociveeavnn No case among exclusively breast fed. In 34 out of 87 | i families affected contemporaneous paralytic disease of | Santa Clara Province, Cuba. ............ Raval district. . avs. fess asian vs vain 140 8% domestic animals was noted................ Petrograd, Russia...’ aos urs vases 29 2% Most cases under 3 years........ccoveau.n Negroes less affected than whites Lebredo & Recio—Sanidad y Beneficia, 1910, III, 170. | NOTWAY rss vonin cs iininsnnnass « vained ave 59 10% Most under 10 years Harbitz—J. Am. M, Ass., 1912, LIX, 782. | WELRIL. ui sian #5 wii «vv viv www wigiee 178 10% Brazil, .. cee cas cannes os vr oms ns mene 13 0 Allunder 2 years. . ..... coves vais snnice Cases applied to a clinic; First occurred in children emi- Ferreira—Bull. d. La Soc, d. Ped. d. Paris, 1911, XIII, 370. 1911, grated from Europe... cov: ides «ox sas cravat v on Vol. XIII, p. 370. Ransas, Th 8. A de. 0 iv is Sn danannn is 100 cu Corresp. Sec., St. B. of H. Qregon, U, 5 A SR gee 3 } i Qorvesn. Sec iy EB of H. or’ akota, U. S. orresp. c., St. B. Montana, U. S. A.. yo 4 > Indiana, U. S. A. les 14 Switzerland..... ........ 1 25 ? Young children... ............ c iss oevoes Few sporadic cases over previous 15 years Landolt—Cor. Shiate. f. Schweiz Aerzte, 1911, XLI, 1144, Washington, D.C., U.S. A.......cvon von EY ns er ti a es sais a Ve ne niles 506 3% Six instances of two cases in same family 84% were under 10 years. ............... Temperature ranged 69.7° to 77.6° F. paralytic disease Report of Committee of Med. Ass. of Dist. Col., Wash. m. annals. appeared among ducks and chickens just prior to the 1911-12, X, 81. ORLDIEBR vis + is ov vida nin id WH nin nian seine nee Anjou, France. ...... ad SY le Sie ees Several small villages. ................ are 18 A rl AT 3 Young children... cv... eis ein ssimase® Grosgeorge—La Polio. Epid. en Anjou. Theses—Fac. de Med., Paris, 1911. | of H | Corresp. Sec., st B. of 3 Corresp. Sec., B. of H IARSTRE Sagat, 2 CT dh ERE IS Tr a — \ | | | 355 TasLe I—Continued. | Year. Season. Place. Topography and Distribut Cases. Death Rate. Evidence of Contact Infection. Age Incidence. Special Annotation. Reference. | 1910........ May-Sept....... wir California, U0, 8, ALL agian cosa aec Bi Disseminated over State......... 139 7% 49, of cases were ‘‘contacts”..... woe nla minis ix AN UNGCTE B YERIS te... «vs vo.viv sniiin sabrs Sporadic cases had occurred for many years previously. Gundrum—Cal. St. J. of Med., 1913, XI, 193. | Paralytic diseases coincident among domestic animals. . | 3910. .« coinc sap vansnavesssns sn SWOHRH, cvs savas sins sos sama vansvaine Geeitie sees sass seis seein 180 LR RABI a RE oe, a SR! TIO SR rT Qe DY RL LB Rel Se CR TLL | 1910.5... ... Small local epidemics and sporadic ug. 32 BO eee esa Ae Ae em AR a 4 Ae ail alias als eles MU AE ae nae ae sae + Ny ps eee We eu e 3 ale reie wee 4 Sleie none ia le aie sn Wintae iclpinie 44 3 % pny | M0... CY es vi viva taste x aie» wo Few 0 Several........... Young children... A few cases had occurred previously, in 1893, 1898 and 1905 Harbitz—J. Am. M. Ass., Sept. 1 1910........ Priscipaily i in the Lehigh Valley, Lane gr and 1,076 22% 6% were *'contacts®... i suai veo. 89% under 10 yea y In 289 instances other children slept in same room but Netter—Bull. d. I’Acade. 'd. Med., 2510, LXIII, 458. Potter Counties... ....t... . oie 29 age not GIVER... Nv. cova ns finn ss only 24 of them contracted the disease. Very few Dixon & Karsner—Am. J. Dis. Child., 1911, II, 221. negroes (3) affected. Cases in following years as follows: | Cases and Deaths Since Reported to the Pennsylvania 3 State Board of Health. Cases Deaths 91L. cs re Ri aeenins seeds va 177 93 IMac oinn sivavies 267 116 1913... cee oven Ves eavee 141 96 9M. vi. Svs rss 113 65 | F015 acres eri ve 162 86 | 106: na ae eed 2,000 500 ] 1910... 5%... Sammer.. caves Idaho, U.S. 8. ai i een es Principally in one county (Idaho) .... . 76 20% Of 41 cases investigated 12 were accounted 897% under 10 years of age. Seven families ...........c..iiiuiiiiiniiinienrniernsanncnnennnanns From Corresp. with Pennsylvania State Board of Health. for by history of direct contact, 13 by had two cases each, one had three, another Hyde—North West. Med. 1910, n. s. II. 327. Contagion transmitted through visits of JOUriCases. ou. stair sr rr ars | . 3 TEIatiVES, , sve r cvtes owns v seule Fe nine vt 1910. .....3 VL TR AR I Towa, UU. 8 Bu in cdi a crite ion wes In various towns and districts.... ... .. .. 654 24% Sixteen instances two cases in same family, 749% under 10 years of age, over 12% adults Impression among physicians that the disease had been un- Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). | . usually prevalent since 1905. Among 12 families (com- prising 70 persons) furnishing the entire attendance of a small country school, there occurred five paralyzed cases, five definite abortive cases, and 13 suspected abortive cases. Weather unusually dry, coincident paralytic disease of animals. Arizona, UW, S.A, |... 2 a i ET a ir vd Vans aide x we eaiele Sus aia de 30 nin ie tapageie + on Ta lee le ake a AL An NC Cp ae a Ak 8 ain RR mn a AALS trv WEE GO Barueintety sera nudes dn ee re llr yA en 4 + aLovett Inf. Par. In U. S. in 1910. | Colorado, | ETT VRE eV SR RRR SC Sa A a wees Sree BO nN evn veh a wines $F ay Slee a A A Re A ht + AE ae A ea ei Dales siete 'w seTe wea. wwe Sir ey Erk ae x + x Ps 4 + Ra aCorresp. Sec. State B. of H. | COMNECtEUE TE, 8. Avs vie vv she ca de ee 168 rien TL RN a A a hE 1 SRR A EL eR nr a i a A AE EA AR a A RRs us nia ee Se ET As ne STARA aLovett. | DelaWare, U. BA. 7. . hes the ste Des a a ans 8 Oly a PER ey rs a es + ne AES oe a Tr on Wa wa as oC eels aLovett. | Florida, Y. SoA. . r.iistuasrrriarnnmss © vt «sodas vse sitiee seal + + aaiana se simi % 19 anal ar lmiele eo AA sv aan eA SARA ea AN a AR AE nN Sn wait a acta Tels ve aie +e eles La eles 41 Da irae ge A ei ee wk an aLovett. HHNOIS, UT. S, A. cr our Tt waviness + Br i a oe sila rea i i ‘a 137 Bienes I er ainteie snnnins ss MR ae aa SHE AREER INR Cae Sa aE aa A Sa ale. a a Sees sen a ea we eitieiaie ss us 0 0 = HATE es Nin van. aFrost. Infiana, U.S. A... inion eran i testes tree Aes veintateidietes 500 Be BT MTs Whuis 5. vs SWRI Reo % Hp A AEA ARR % 0X OR A nn a 3 A A ER Suh a a Talula le LL vara wi a EA Eata ta us Aiba ity sie shee wre mie a ean ey Vie ee aLovett. Ranma, U. Buh. visita rss os rinmrnr aiiaie £4 4 4 eas de eu tne «alent eak 198 RR EE WT TWEE 4 4 te I aD a a 2 Lr IE I pO IRR ie LIE RRL aLovett. 1910... os eed nae rasan RentuCky, Ul. 8: A... oc cue csv in he inns a tans tints $60 weit ote o vio vous Sialaie ia 3 a A Rs ssnnin da AAR anno FREER fran ns Re vx wd aan ae AEA SAR ar rR We anf sierins s SR DRE ie Sam Cu ey Py Se «Hi aBatte, Dr. John. Cincinnati. 1910... iui irene Maryland, U.S, A... 0 te carn tncea dans Las sve isin desis vs mia niet . 300 Ee A ER i EE RE RH TR ORE RS OR BERS IR ST aLovett. OHO, i.e od eS re wk Massachusetts, Ul. 8. A... Li ii ori vii cit cns wove ainie «maim aielntaininiate 843 a Fa Rs a Re ee igi, or Gen er Wg eT) Il pe Lo a To ah a, po, aLovett. { Cases and deaths since reported to the Massachusetts State Board of Health. 3 Cases. Deaths. 3 * " bCorrespondence with Massachusetts State Board of Health. 1 169 6 ik 361 69 TN ee aE El ne US RT Re TES UIE. ee dh reve eins vr ih 2F 151 45 : 135 32 3 A 924 395 1910... cv. nine sae Michigan, Hillside, U. S.A... ii ce lc iieerns iii Penns ae ne vaantae ia - 5 72 D2 i ia enn CAA a AT wt yan TREE thn nn VEE 1 kas 3 AAR wa OAR TR as vt ot a a AH Ae 3 Ren Ak ea Ae iw aGreen, Dr. B. F. of Hillside. I Cases and deaths since reported to the Massachusetts State 4 Board of Health. 4 Cases. Deaths. i OM. an a 115 58 % B902 vec rve ci Tne vaniv danas 35 23 Minnesota, U.8. A..........v.vesns. in aLovett. Montana, U.S. A...... 30 aviv, of aLovett. Nebraska, U.S. A... 5... 5700 as aCorresp. Sec. State B. of H. Nevada, U. S.8..u...... 0 .inuuiiinnoey aLovett. New Hampshire, U.S. A................ aLovett. North Dakogs, USS. Acres oni ves . Ohio, US. A......... ir v aFrost. Oklahoma, U. S. A aLovett. Oregon, U. S. A : : — aCorresp. Sec. State B. of H. South ud LSA... ahr ere aBul. S. C. State B. of H. Rhode Island, U.S. A... 0. 0 06% . Frost. South Dakota, GSA . aLovett. | Utah, Uo. A... ina ins aLovett. . Nermont, U. Si A. a ling . aCorresp. Sec. State B. of H. Virginie, U.S AL... Lm, aCorresp. Sec. State B. of H. Washington, U.S. A... cq. cides ce aCorresp. Sec. State B. of H. Montreal, Quebec, Canada. ............. aColin Russel, Montreal. Ontario, Canada. 0... vii ariviss alovett. a For authority for reports of the 1910 epidemics, see pages 18 and 19 ** Infantile Paralysis, Frauenthal & Manni ring.’ b Data obtained by correspondence with the Massachusetts State Board of Health. ——— = TET me TT i ok " TTT Tid - “Tht A a av . SE Er {eh Fh er SAU BY Rie ee aenagee) ied TE; AS I $5100 Hoan EF : Pc UAatemy gore gov op He 5 w : EI mes : i Lo = ih Nh rr Vite. yoo nA BESTE Dey rin) FRR SC LC JR Ted ITY Pes TOE a §isieny * A 5 FQ ICRIGL rn Ce vA a 357 TasLe I—Continued. Year. Season. Place. Topography and Distribution. Cases. Death Rate. Evidence of Contact Infection. Age Incidence. Special Annotation. Reference. 1900. cr. edie arr British Columbia. . «sve (eves coisas ie vritin ss vous “wn mn we ale sas ne ere we Nv 75 «si i PR EE Sere gM Ea LL Ry a a LER a Te aLovett. 1080... rT reas ieee United States (as a whole)........... SB A A rite verses miresse- 14s390 20% Bann vi SE rr PE RCC x eke eee Ee SE PEA ae Ee Estimated from the 1,459 deaths reported by the Bureau of the Census. 1980.0. vs poi id wn un la Schleswig-Holsteln..... onsen so dais va 132 ry ey yes ST eH mn ver saa aE Wa A A ka At tS aE eh Ea ae a ee I ls aie se let a Ws izes is We Satan Wie sl ae igi ie 8 aMeyer. 1908. ...0. Oct~Dec.. iv. vos California, U.S. R..v i dvs vain sia in 55 249, 3% of cases were “contacts”. ........... 72% under 8 years. vd Sporadic cases had occurred for many years previously. Gundrum—Cal. St. J. of Med., 1913, XI, 193. Paralytic diseases coincident among domestic animals. 191.0. TOC ~ Det rv a vis Sweden......... St ar viele rE ae . 3,840 BOG A RR se ay Ee as +. Mostly young children. ................. 75% of Sweden's population is rural; 39% of this was The State Med. Inst. of Sweden—Report: Investigations on attacked. 199, of cases in towns 0.1% of population Epidemic Infantile Paralysis, 1912. (urban) was attacked. Areas of prevalence during previous years nearly entirely free. Budapest, Hungary... ...... coed. Joven gies suns ; Mostly young children. 4 a Cincinnati, Ohio, U. S. A. . 150 31% Nine secondary cases. 96.9% under 10 years. . vic... s ernie ws Weathie; unusually rainy. Coincident paralytic disease Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). Of animais. Buenos Aires, Argentina................. 39 0 0 All under years... Jc. vive dans eres LT LE OER Rr i ee Sy J, Acuna & Schweizer—Rev. de la Sod. Med., Argentina, 1911, XIX, 449. 190... May-Aug.......... Poland... .. ir esrves snianoninn nie sacs Mostly in country districts. .......... caeh vs 166 B00 enmwiaie ve oe rn aan a TT Only-five cases Over 10 YEAS. i... ivisv vis vit wens wrimnlniain s vie sniels tx sss a hws mons vos ve ds wie wns DeBiehler—Arch. de Med. des Inf., 1914, XVII, 1. 1010.50. Summer... ...oo. NOTWAY. . i diab vit vas ul edd dues Over large tracts of country. ..... os Semaine 1,250 10% Two instances of two cases in a family... 759% children; 25% adults. ............. Since epidemic of 1906 only a few sporadic cases had Harbitz—15 Internat. Congress of Hyg. & Demog., 1912, I, pt. 2, occurred; one family of nine had two acute cases and 577. 1911... . -.. Summer... . v7 Englant.. Lvl i GTR Se eR ax AE Rural districts in Hampshire, Devon, Cornwall, 229 21% Two cases in each of four families; three seven abortive ones. Norfolk, Staffordshire, Huntingdonshire, cases in one family. Mostly young children; 5% adults. ...... In small hamlet in Devon some one in nearly every house- Cross—Brit. M. J., 1912, I, 721. Suffolk, Derbyshire, Oxfordshire. hold manifested slight illness but only one or two cases Local Gov. Board—Grt. Brit., 1911-12, XLI, 29. developed paralysis. Tomkris—Brit. M. J., 1912, I, 182. England—Brit. M. J., 1911, 1691, II. Roth—Lancet, 1913, II, 1378. Gregor & Hopper—Brit. M. J., 1911, II, 1154. Moss-Blundell—Brit. M. J., 1911, II, 1157. Saltan—Brit. M. J., 1911, II, 1151. 1981. renee SUMIMer, «. iss » aves Birmingham, ENIand.....c. i: covivaesnsli:Cs sien « vr ae suis seivissisioies Eg Ry 150 Be TT i ennai rrr» de ea a Mostly young children. ................. Sporadic cases in England since 12 cases reported by Hillier—Brit. M. J., 1911, II, 1690. Jubb, in West Kirby, 1912-1914. Moir—Brit. M. J., 1911, II, 1693. ws Jubb—Lancet, 1915, L 67. 191)... viees Feb~Sept......... Louisiana, U. 8a AB. div. isvicdsiannesns Rural (Morehouse Parish). ................. 60 25% Contact of most of the cases was traced Between 1 and 10 yearsof age. .......... Of the 60. cases, 52 werecolored. .......svcrviaeessonnn Patterson—N. Orl. Med. & Surg. J., 1912-13, LXV, 812. either direct, or through relatives. Bed- ding used by poliomyelitis cases, washed by mothers of several cases was also blamed. One instance of three cases in a household. Four instances of two cases in a household. These included two cases in one family. ... BOIL... Ciena is ewer v tin vin x wilh Indiana, TeS. A. ico dvvnvvsnnsvesnaes « wn Suln sien swans « He ieein r ¢ ur nn sns Salis sieivie's 102 N00.000 7 ates Bes oe Sn Ee a Sr ae a vn ET SRE i SARE aR aA Pa a aKing. B90]. viene Ser RR re Virginia Mountains, U.S. A............. ET wR eer res Sree ey 25 LE OIA Pe aw PR | Bu a SL SO LS LRH aEvan Evans. QOL rls ave anes Rr en rms United States (as'a WHOIEY. . .. icc slits cov ons sioiovrnsnvianesinse JES ure rae etre 1,930 GRU RE SN sin rane tina a wR sr et a $Y RAR AN sR NEE ba er 308 LR as wate re 8 Bureau of the Census. Uk PR I ERA Denmark... intr rn at rns es re Areas CRA sys sn 8 acu eins wleatee ute 250 rr Aas aaa Sle a AE ENN Ri SR eR Ew Calan on AEE 8 x Elen eens Aa a Hea. aThomsonn—Hospitalstidend, liv., 1329. 3 NL TL Germany............ esenb eee rmns arn eeressesnusns stress enst era. crvees 1,000 Fray Sa Seen tester te aR CR Se ye ie en aa ety ae aa Sk kv Re EC aSlomann, Copenhagen. 1 Ra, Oct—Dec...:..c. x: Basle, and Eastern Switzerland........... Town and ‘country SA Bos 43 10 Twomonths to 11 years... ....c....v va Brandenberg—Cor. Blatt f. Schweiz. erate, 1912, XLII, 1265. 1912.4... June=Oct....... California, U.S. Avsivveen coins Disseminated over State........c vu snienvses 531 24 8% of cases were * ‘contacts. 78% under 8 years of age. ............... Gundrum—Cal. St. j. of Med., 1913, XI, J012, . dure SUmMINer csv. vos 20 Bavaria, Germany... cus. vii sines Mostly rural districts... ... coor omens env 197 10% Five instances of two cases in a family. . 99% under 10 years of age............... Uffenheimer—Muench-Med. Woch., 1913, TX, 2833. Three instances of three cases in a family. (only 13 of school age) 1012... 5... SUIINer. o.oo SWEAR avinisidne + sits saisinsis as vs vie caine nies Mostly rural istrict... co. ivi Blinn. os 1,458 10% CR ARR ST ET ry vr Sats sve Re re a as RENTS Few wee vie bis aie Kling and Patterson. 1912... cs rsp nne ite ue NOIWRY . veut iis rani vss sss arsssssnrinel varsnesnsesy Sry ren rete anes aRieie sree 117 5 rr vx ve a Ferme sds ver ci ta ie wan ane Sat ea EEE alae Pe er aHarbitz. 1913.0 vnavs Summer... vo ov re Baden Duchy) GEIIANY i «ssi snivirs vere yo Crass esos Ce eh elie pein ans > iind Wide o inns ie aren by Vcr SR ary 1913. 5 vs Covering period Austria (various provinces). ............. Mostly rural..... enn Cr are sles ia eles 187 15% Five cases in one, four in three, three in 66% under 10 years of age............... Stiefler—Wien Klin. Woch., 1915, XXVIII, 1079. since 1909..... we three, two in thirteen, and one in each of Vermont, U. S. A Mostly in and around one town. . vasa ers Mostly young children. ................. Alaska (central).......... Indian fishing villages on Yukon 30 13% Mostly young children. ................. Epidemic was preceded by a great epidemic of distemper Pierson—J. A. M. A., 1914, LXII, 678. Hong the dogs in which paralytic symptoms were Cn a ENA a Re IN REL 1984... ...: Summer.....v. vive Vermont, U.S. A... cui nirernnnies cus Disseminoted: ; cooiivi sv asinvions voins sie vieisie's 149 ? rae ee CF Dv a nA lee Young children... cou. 0 5s saiiviagsss Cases applying for treatment of paralysis (those from Lovett & Martin—Vermont Med., 1916, I, 36. 5 er = previous years not included). ...........c00ueurunn.n 1914... os July-Oct. ...... ou. Vermont, USSSA. coin ivi vain oo Mostly in and around two towns. ........... 304 17% In only 68 cases contact with either a frank 66% under 10 yeatsof age. ............. No case developed in town of previous year’s epidemic {2 Caverly—Bul. Vermont State B. of Health, June, 1916, XVI or an abortive case was shown. In 210 44 cases (18 over 10 years) with a mortality of 25%, were No. 4, 2. families each developing but one para- reported during the following year (1915). In 1916 there lyzed case there were other children to a were 61 casesand 13 deaths............... ive en total of 619... coven. ve A RT a For authority for reports of the 1910 epidemics, see pages 18 and 19 “Infantile Paralysis, Frauenthal & Manning.” t Quoted by Frauenthal and Manning in their book “Infantile Paralysis". }2 Caverly—P. H. Reports, 1914, XXIX, pt. 2, 2826. &@ eon Sn GT 359 TasLe IIL.—POLIOMYELITIS IN NEW YORK CITY AND STATE. Year. Season. Place. Topography and Distribution. Cases. Death Rate. Evidence of Contact Infection. Age Incidence. Special Annotation. Reference. 190%...:.:., Principally Summer. New York State, U.S. A................ Schenectady ((OWN). coos vr voien sivas vines ve 29 7% There were some 2,000 children in 752 66% under 4 years. .... RR +..... Sporadic cases, approximating an average of 100 a year, Clowe—Albany, N. Y., Ann., 1909, XXIX, 799. families in which there occurred one case known to have occurred 1897 to 1907. This is based each. In less than 18 instances more on clinic attendance of paralytic cases. the one case developed in the same amily. Principally Summer. “New York City, N. V., U. 8. A. ii deal cera Frese valves suaivin FA en 2.300 (est. Yo S00 Aesth.) nvr. sft pin un ts VR en RE ea 97% underd0 years... cui ns isvnnniwane Sporadic cases, approximating an average of 100 a year, Nervous and Mental Disease Monograph, Series No. 6, 1910, known to have occurred 1897 to 1907. This is based N. Y. Acad. of Medicine. Principally Summer. New York State, U.S. A..........00ntn Prevalent but no data previous to 1909 except on clinic attendance of paralytic cases. as given for epidemic of 1907. Principally Summer. New York City, N. Y.,, U.S. A........... 3 x . Principally Summer. New York State, U.S. A...............0 Exclusive of New York City................ 1205 ol an ir Fp rene sts tetas vr iste Ru hil y nuns su bse grea nta ve mee ose eens nee ot tiaaiitne aise Rie a vee Sap Rb Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). eaths Principally Summer. New York City, N. Y.,, U.S. A........... 1320 EAN § ATEEISrMEserssareslys ans sek essgeces Ce nnie vere Veena vie we snes Cn aie Dr. Legrand Kerr reported 150 cases in Brooklyn Borough. Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). eaths Principally Summer. New York State, U.S. A.......covivnnnn 322 A SR EI En et eg A Se Te Sel via wR ales ase ane IN ama ly err ie ene nea evr ine vary ane a «Hee lee “ Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). Principally Summer. New York City, N. Y.,, U.S. A........... 1275 2% gu FEE Y seers rerun sents Riss tr stir an esaten coders fine A ragersn ings sheen rset ler en sein Cre ensuite vas samy, .. Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). eaths Principally Summer. New York State, U. S. A..........000nnn 138 120% ot EER ts Te weNE PA RING fA RN res mt rae ae a ia een 4a A i 3 wae eiage var sae Ces Sates ere. seh . Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). Principally Summer. New York City, N. Y.,, U.S. A..,........ 358 20% 5 risen sreeeasenaniaresirtararns ass eae Wanna Eee AA Aaa ANS es aE see saa easter esas tarany Caine uate Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). Principally Summer. New York State, U.S. A....... ........ 604 219% Tiree A two cases in same 90% under 10 years (Buffalo)............ “Study of epidemic developed nothing new” ........... Frost—Hyg. Lab. Bul. No. 90 (U. S. Public Health Service). amily (Buffalo). Principally Summer. New York City, N. Y., U. S, A. 504 149, City Department of Health. Principally Summer. New York State, U. S. A..... 183 36 State Department of Health. Principally Summer. New York City, N. Y., U. S. A.. 310 17% City Department of Health. Principally Summer. New York State, U.S. A............ v 95 31% State Department of Health Principally Summer. New York City, N. Y.,, U.S. A........... 129 26% City Department of Health. Principally Summer. New York State, U.S. A............000n 162 19% State Department of Health. Principally Summer. New York City, N. Y., U.S. A........... 95 149, City Department of Health. Principally Summer. New York State, U.S. A... .......c.unus 3,500 25% State Department of Health. Principally Summer. New York City, N. Y.,, U.S. A........... 9,023 27% City Department of Health. peared, 8,287 had but one case each. When there were more than one case, in nearly all instances, the onsets were so close together that simultaneous infec- tion was suggested. *Death rate, according to Holt, was 129%. TEstimated. 361 TasLe III. Poliomyelitis—Cases and Deaths by Date of Report. Manhattan. Bronx. Brooklyn. Queens. | Richmond. The City. By Days By Weeks il iiss tE lis ll ELIE SE < @ a o < 0 a © « oS © © & © o A oO A Oo A o A Q A o A o A May: 1=12....%.. No |Cases 33.000 00s 1 Tr 3 1 14-22... cv. No [Cases 23aeicann any oo 3 1 1 eh ie ase vi 1 1 1 2 on 6 es as ww os . 2 a vie 0 2 Te x TVovionsins is v4 i he #5 1 os 1 1 we Snrnivey ny + ahs 4 Ae Jed vi 4 fe oe 8) fs ioe ein Gs x 3 ol a "ey th ve 1 en wy 10. 2 op AA 2 aly ov Ts 4 a 11 2 31. ea te Fp an ty 1 .u “ie oo 1 wes . AZ suk eo od 2 Vs aie sie 2 4 he 13. 0a vein l 5 > 1 1 oi ou 2 1 3 M4... 2 ou os 2 ie i) 4% 4 se Wy; 18. 0000s 1 5 ve kn ¥e ot oh 1 ie oy 16-0. «iv. ir wy 35 3 2 os a 3 3 cain oe P70..00. oo vy 5 3 1 wi 4 3 1 15 3 8, cies ns 2, he IT 1 a. nls win 1 wine ae 2D, tin iis 1 ct A 1 oly ie i 2 os D0, crite ck 4 i 1 a 7 1 1 1 9 2 2b. a ra at ir 12 5 0 vs 12 5 DT iain wi 2 or ui 16 1 vi oe 18 1 23. vals 1 - “ie 42 1 i - 43 1 vive oa 24. vies 1 Fi! shy 12 2 oi + 13 2 97 12 2S cuvn nas he 4 10 9 Vid 0 10 9 pl Fe 20 %ie sie wren vid 1 “0 ut 22 3 1 3 25 5 2] ieenan aie 6 2 oh 38 5 ol ng 44 7 OS aa be 4 3 vd 23 6 1 2 30 9 DO eer aa ny oi wii 45 10 1 3 49 10 30. 1 2 1 38 6 ote oe 50 8 July Lesa tr 8 ty 2 1 45 10 4 2 1 61 12 269 60 Doe aly 5 1 3 .s 18 17 oy 4 6 ve 32 18 pw = 3. vii 8 1 3 We 20 8 if 1 9 4 41 14 Wd iinie o % nis 9 Pe 7 $i 1 24 aie Sia .y 86 24 S rae 10 1 2 1 80 7 5 6 Te 103 9 AEA 16 2 3 2 90 21 Loui 3 A 113 26 rien 13 2 3 ie 60 15 3 2 8 2 87 19 oh o's Sie via viel 12 a 2 or 74 13 1 2 6 ba 95 15 357 1125 el hee 8 3 3 we 66 14 8 1 3 1 88 19 ed Tie 10:7. 30 3 Xe 1 77 9 1 ey 4 11112 14 I... nhs on 13 6 7 3 {151 20 13 3 6 iy 192 32 12... cons 13 4 1 iy 131 12 13 1 S ee 163 17 130 icv vin 17 2 3 +4 76 18 12 3 10 1.118 24 Mie co, 14 6 6 a 122 16 11 8 9 1 | 162 31 vie ws IS nde os 30 7 4 ne 87 16 12 2 11 2 | 144 21 979 | 164 100. 14 4 6 ox 65 9 6 2 5 2 96 17 vee oe stir «nx oi 18 3 1 2 65 7 20 2 1 2% 105 14 IS heii ite s 7 2 3 yi 83 18 13 4 15 2] 121 26 19. cnc us 26 3 6 is 82 19 13 4 13 4 | 140 30 20. eye 13 3 1 2 81 23 13 3 7 : 117 3 20: 16 7 4 1 36 16 14 7 11 1 81 32 a i 22: nuvi 23 9 5 2 82 19 17 6 8 3i:135 39 795 | 189 23 eins i 28 3 5 2 58 14 18 2 6 24118 23 ine te 362 TasLe 1II—Continued. Manhattan. Bronx. Brooklyn. Queens. Richmond. The City. By Days. By Weeks. ow w w a ui w ow ow I] b I] Z 3 I] 3 © & g 7 I] « U © [1 © o < [9 © [ & o < u o A o A oO A o a o A CO Aa o A July, Continued. 24 18 6 6 1 53 19 11 4 1 1 89 31 42 9 12 3 73 23 16 2 S 1 | 150 8 42 12 5 4 83 9 25 7 7 3 162 35 31 7 6 6 90 13 18 4 6 1 }:151 31 39 9 5 2 72 15 11 1 7 2 134 35 nt oi 46 10 13 5 66 24 29 5 7 “a 7161 44 962 | 237 40 2 Z 76 9 15 2 7 145 13 ye a 44 9 8 1 59 20 21 5 '% 132 3s 42 12 8 - 83 33 17 10 9 159 35 46 17 8 “ia 88 16 20 8 4 166 41 76 14 8 2 92 21 33 8 8 1 217 43 Iv 52 10 9 1 84 32 28 2 3 dui 1276 45 sis A 51 7 7 2 83 22 27 9 5 1.1 173 41 11,167 | 273 45 12 19 3 93 9 34 Y 1 2.4192 33 rs or 38 9 5 4 79 24 19 7 4 145 44 54 15 9 1 89 29 31 8 nt 1 183 $2 47 14 15 7 89 21 31 13 1 oo 1183 57 44 9 14 3 84 20 30 6 3 wr 1175 38 rs 50 7 10 6 73 10 28 7 4 1] 165 31 he i 56 1s 17 4 61 19 30 1 8 sme 2167 42 [1,210 | 297 49 10 21 2 54 8 16 2 1 uit 141 22 Pas oie 43 14 8 3 31 12 13 2 os 95 31 51 13 13 5 74 14 30 6 s 11173 39 44 8 11 Z 46 14 28 5 4 133 44 39 10 10 3 40 10 32 9 121 32 44 17 8 vie 48 6 20 7 5 2.ln12s 32 a Pe 52 12 12 2 45 15 25 6 ‘e 1 134 36 912 | 236 37 9 13 2 40 6 14 3 2 108 20 ‘ok oe 32 17 9 6 29 8 21 2 1 92 33 . 48 19 9 4 42 11 16 4 3 1 | 118 39 ‘3 52 12 10 6 43 15 23 9 3 13 42 ols 59 12 ol 31 14 10 4 3 1 109 31 oe 43 14 14 1 24 7 1! er, 2 94 22 ox 36 9 13 13 27 8 13 ns 1 3 92 25 826 | 233 36 Ss 10 4 27 8 9 4 1 83 21 a 20 11 7 3 7 10 8 1 1 43 25 30 10 6 2 33 14 12 4 ve 2 83 32 37 7 11 3 27 S 13 7 1 89 22 26 10 3 4 25 6 6 1 60 21 34 8 7 1 20 5 5 1 2 2 68 17 wy va 27 7 9 1 13 10 ii 1 1 61 19 487 | 157 23 11 9 rhe 13 4 5 2 1 51 20 he 4. 22 4 7 2 9 8 2 2 40 16 13 9 8 4 12 7 6 1 2 43 21 26 9 10 3 10 8 5 2 2 33 22 30 7 14 4 10 13 7 3 1 61 28 23 8 6 1 11 3 7 2 1 1 48 15 pid oe 24 3 8 a 14 3 9 3 1 33 10 351 | 132 20 8 3 1 12 4 9 1 44 14 tae i 8 6 4 os 7 2 1 1 20 9 19 . q 5 1 8 7 5 Ve 1 38 18 9 6 8 1 8 2 S 1 31 9 19 9 6 es 7 1 4 1 36 11 24 6 8 1 3 1 7 2 42 10 cig Ln 13 4 8 1 13 4 7 4 41 13 250 84 12 7 1 5% 5 2 1 19 9 SE #14 3 2 2 1 6 2 1 1 1 1 15 6 12 4 10 2 9 6 4 2 35 12 8 3 6 4 3 es 1 2 18 10 10 3 4 5's 11 2 2 1 27 6 9 3 3 2 5 5 3 1 20 11 lo h 13 2 2 1 4 2 1 2 26 7 160 61 3 1 2 1 8 3 2 1 15 6 ne ge 6 3 3 sie 3 2 2 Te 14 5 5 7 9 A 1 1 5 3 20 11 10 3 4 1 9 3 1 26 S 13 4 4 2 4 3 4 1 1 26 10 12 3 6 1 5 4 3 3 1 26 12 sir is 9 1 6 2.1 op 3 1 19 4 146 33 363 TapLe III—Continued. 5 eam SE Be eae es CS whe a SHrenn ewe ow ~ 2 gqyeeg i - de. Wissen eo mde OF > 5 vie won -— = w= al oth ep Gen pee fees SSP wel ~ S TSORBPY | en a Ea ie a er tr ae ARE ST Eh RE El & goseqfii marae ne Sir Bains $a # £ 5 ~ . oe “oe = g sypreaq \O 90 0 NOW DNC Hr Hil) Hen 13 i 0) sree > ON 2 vey © a > . CONMMANRMIN = ISL AILS ISO 08 0 OM IS IS 10I0 — o I SIsB)) ON] tt —- a ae BE Cr Ei A i el th A ee End ear EE lel Ty TE ce cg fe gaa Re Re fg fe Bap iS ru ie ele lial a a A o £ 2 *SIse)) Te TT atm, ~ . ——— wiv Ta +a. wn Pt ir wnle Lx Ce cae de - ~ g SIO ite a a os a Tada fra 0 @ 8 ‘sase)) fT IY rin WR g CON AN re ce SN NIM ee ss N= oe sea . Say > whe are rs ~~ Q g NONFANNA NN mA NNN mA ce ‘S9SB)) . . =. . . m * Ce —A Vor Reb wa bE « J SIRI Rn ree ty fr aie » = 2 m ‘saser) PND OBO pri rel aS oR See ue EN g nna nama aN —-n . Cree 3 a syreaq +n ” 4 0 — wt Ne ar > pet £ a . FOHONFN =F NNIN—=NN=FNNNNO NIH NN = "S9sB)) —- : . ~ CNMI INONNOO— s —-— Q 304 TABLE POLIOMY Cases Reported June 1st to Total All Ages. | Under | 1to2 2to3 [3to4 |4to5 Total 5to6 [6to7 1 Year | Years. Years. | Years. | Years. Under Years. | Years. 5 Years. Both | M. F. [M.|F.| M. |F.| M. |F.|M.|F.|M.[F.| M. F. [M|F.|M.|F Sexes New York City— Jane. ...o.0s 0 756] 416] 340! 50| 39| 104| 83| 105| 88| 57| 62| 41| 26 357| 298| 22| 22| 11| 3 July. tsi os 3,863 2,201 1,662(222(200| 435|334| 561|365/386/271(200(153| 1,804 1,323(138{109| 86| 71 August......... 3,306| 1,905] 1,401|209(166| 361|247| 400(296/300/214(201/140|1,471|1,063|132/108| 80| 51 September...... 780| 435) 345| 45] 34 89( 76 83| 66| 65| 56| 43| 26] 325 258 35| 14( 16| 14 October. «vv vs « 193] 101 921.71 10] 21| 18 24| 15] 12| 18] 11] 9 75 70 7| 6] 9| 4 November...... 16 3 13), 11°56 Tel ly eg Bp eon <2 1 11 ie December. ..... ole Seles we vie a 5 Total oven . 8,914| 5,061| 3,853|533(449| 1,011|764| 1,173(830|820(624(496|356| 4,033| 3,023|334(259|202|143 Manhattan— June.. 76 41 35; 3 1 10| 13 14) 74 71.9]: 4} 3 38 33 NM Uo ..).¢ July... 829| 471 358] 60| 60 107| 85| 131] 69] 67| 55 33| 27| 398] 296| 20| 17| 14 9 August.... {1,191 672] 519] 88] 71 131(107| 142|118(|103| 66 62| 45| 526] 407| 48] 28|-26| 21 September...... 342| 192 150] 29| 16 44| 36 420 321 26| 241 1S; 12; 186{ 120 15] -6; TiS October. ....... 89 50 39] 5| 4 13; 11 12.302] 9 ~Si"2 36 29 § 52 November...... 9 2 Zire] 0s « lS si rey FE Salen oo 6 .. .s December. ..... oF ie Te ve I. 5 Total. ic. hes 2,536] 1,428] 1,108[185(152| 305|255| 340(229|205(165|119| 90| 1,154] 891| 89| 53| 52( 37 The Bronx— Jane... ...... 10 4 Ol «rf 2 1-1 deal Gnd ow. 3 Ss a 1 1 THY. es vrdeies 174 85 89 7 6 12] 20 25( 18] 17] 12{ 12| 11 73 67 4 4 3 5 August... 332 184] 148| 19] 21 271-19 38| 29| 27| 21| 28| 17| 139 107| 11f 12| 10| 6 September...... 142 81 G1" 8] 3 13} 14-12-11) 13] 15].14; 3 57 45] 4 2; 4 2 October, .v..... 47 17 30] -.] 6 2 4 4) 8 4| 4] 4 3 14 25] 1430-301 November...... 3 vie 3 wa salt 2 ie rc) ieted fede gE aoe 3 oi} ee te 4 December. ..... or vie oe a 708] 371] 337) 31] 38 55| 57 80| 67| 62] 53| 58| 37] 286 252| 20| 21| 19] 15 626 341 285| 46| 35 86] 66 83| 76] 47| 49| 31( 23| 293| 249| 18] 19( 10( 2 2,206 1,276] 930({124|110| 254{179| 325|203(232|158({104| 90| 1,039 740| 83| 72| 50| 38 1,208 721| 487| 71| 56| 157| 85| 159(107|115( 88| 78| 51| 580| 387! 36| 33| 28 13 195] 105 90 8| 11 217 25 20] 151-16[ 9° 7j: 5 72 65| 10] 2 4] 2 26 13 33) at. 1 1 qt-° 21143 3 7 Ol: Hiei 1 1 November. oe 4 1 3{ = 1 1 i «s) ‘2 woe 1 20 .. . December. ..... ye! os ae Joke Lia ae Total. ... ..c 4,265| 2,457| 1,808/|250|212| 520({357| 591(403(411[308(220(172| 1,992 1,452({148{126{ 93| 56 Queens— June, cove nis 10 5 Sl aerate : 2¢ 030 1) oa tk.. 5 Steed wr, July... coe anny 471] 265 206| 29| 17 44| 38 57| 53| 51| 30| 34| 21] 215 159| 19| 11] 13| 14 August....... 5211 296, 12285 27 17 43| 33 50| 36] 53| 35| 27| 25 200| 146| 33| 31| 16| 10 September...... 87 49 38 3 4 100" 4! 8 70-78-61" 3 36 24] 6 «3{ is 5 October... ..... 31 21 10] 1{ -. Sye2 5 {i522 18 Tae 2 2 November...... 3.96 32.73 28.30 6 to 7 years... .. eaves 345 202 143 92 45 47 Rate per 1,000 Pop......... 7.73 759.06° 6.39. .2.06 2.02 412.105 226.67 7°40 B years... ..... suns 226 115 111 67 38 29 Rate per 1000 Pop......... 5.15 5.24 5.07 1.53 1.73 1.32 29.65 S109 years... ..osnetiae 157 f1 76 36 18 18 Rate per 1,000 Pop......... 3.72 3.87 3.47 .85 .86 B34 22.93 Oto 10 years... .....ush 111 62 49 32 18 14 Rate per 1,000 Pop......... 210. 2% 2.40 .78 .87 .69 28.83 Total Under 10 Years...... 2A5R. 48% 3661 2274 13% 938 Rate per 1,000 Pop......... 13.20: 20.58-. 15.79 4.88 5.70 4.05 26.79 /rs. and Over..... 426 234 192 132 73 59 i 1g NK BEB 6 0 Rate per 1,000 Pop......... Death Rate Per 1,000 Estimated Population at Different Age Groups, City of New York. (June 1st to November 1st, 1916.) TasLe VII. POLIOMYELITIS. Casts AND DeatHs BY COLOR, AGE AND SEX. WHITE. NEGRO. Both Sexes. Males. Females. Both Sexes. Males. Females. Cases. | Deaths. | Cases. | Deaths. | Cases. | Deaths. | Cases. | Deaths. | Cases. | Deaths. | Cases. | Deaths. Totalallages. vans 8,805 y 5,000 1,385 3,805 987 109 34 61 23 48 11 Rate per 1,000 population. . .. 3.83 1.03 4.35% 1.20 3.31 .86 2.41 13 2.94 1.11 1.97 45 Casedntallty.. 0. nr va rae 26.94 Be 27.70 Zh 25.94 Ss 31.19 Sg 37.70 bai 22.92 Under lyear....:. .osniv 967 413 322 232 447 181 15 10 11 8 4 2 Rate per 1,000 population. ...| 18.50 7.90 | 19.71 8.76 | 17.34 7.02 13.70 0.1371.-19.30 1 14.10 7.38 3.79 Casedatality.. 00. 2 oe Sein aay 4271 Ap 44.45 mai y 40.50 we 66.67 sas 72.72 a 50.00 Under 5 years. «oun. ui cuss 6,977 1,868 3,987 1,110 2,990 758 79 29 46 18 33 11 Rate per 1,000 population. ...| 28.33 7.55 1:32.00 8.91 | 24.56 6.23 23.88 8.17 128.97 11.26 19.31 6.44 Case fatality... oouies vv wi Sr 26.77 ia 27.84 20 25.35 Ea 36.71 as 39.13 lo 33.33 Under 10 years....... cols 8,386 2,240 4,767 1,313 3,619 927 102 34 60 23 42 11 Rate per 1,000 population. ...| 18.22 4.87 | 20.37 3.07 15.53 4.05 17.48 393, 2.57 8.27 13.76 3.60 Cascfatality bt 20. coe Tar 26.71 ie 27.55 9 i 25.61 a 33.33 a 38.34 srl, 26.19 10 yearsapd over... vuvv en 419 132 233 72 186 59 7 1 6 Rate per 1,000 population. . .. 23 .08 25 .08 .20 .06 18 .06 .28 Casedatality..o=. 05.0 ve on eg 31.50 oh 31.03 Sr Sv ce (ds TA £9¢ Cases by Onset and Deaths TasrLe VIII. POLIOMYELITIS. by Day of Death Based on Meteorological Data. MoNTH OF May, 1916. MONTH OF JUNE, 1916. MONTH OF Jury, 1916. z E 5.2 5 z E |5..~ 3 z E [4 3 8 v ° SS 3 ° o ° =e 5 ° o o oo 3 AB. 21 EEN EL 2 8 | 2 BEE t |Z AE. 2k 2 Eli s 180.93 5 3 || 58] § [|R dl gay eal H. S ||Se| ER g [Eoi.aal 5 Boll Sef ED Date. | & | =E [E8Z]| 55 lg 28a] © |» | Date. | £ | TE ESE] £5 Lz 285 © |p | Date. | EF | mE SEE Ep Lx g2=r Cy ° v8 SEE <2 2 Eel mw {2g 9 08 [SEY «x 2 |8g°| » |2g v v8 [SEX «x £2 8c » [23 & 5. [mse] [Z| E85 [E58] 2 z= org MoE (2 £E Eeg 5 | 48 | 5. |®sE| [S| EE |ESe| 3 2% ag To I=CB| ug £5 |SgE| = S53 a SQL [=SE| vg £3 |ggs| @» £3 1 TI |=ST| og S53 |TeR| ® S$ § [2252 B2| E22 2%] % | § | 22328 E2| Ex |2E3| § | ES § | 5258 EZ | Ex 24d] § [EA 2 |E |= B a [O Sel 2 |Z |= 2 a [0 oil 2 2 |= z a |O gi8 55 70 0 6.8 9.9 4 . 65 42 0 10.1 14.9 1 19 . 74 43 0 118.1 3 90 8 64 51 T 17.11 - 10.8 8 = 66 54 0 17.87 "13.7 2 40 74 741 07 [22.3] 12.2 7 72 | 26 60 61 0 9.5 7.3 8 Ta 62 81 10 | 15.8 4.4 9 11. 73 68 | .10 | 17.4 6.7 7 94 | 14 62 63 | .04 | 10.9 10.0 3 ot 64 47 0 22.8{ 15.0 4 S| 68 61 0 21.0 9.0 6 | 108 | 16 37 75:7 .28 9.9 Set 8 he, 67 63 1°.02 | 13.4] 11.5 7 OS] us 63 86; .09 1 11.2 0 10 | 106 | 24 62 56 iT 14.01 "12.0 4 oh 66 64 0 9 8 11.8 6 6 1 4] 60 0 11.3; 13.0 21120 | 18 62 70 1-.17{ 10.0 0 10 2 = CROHOH = CON OHHRH = FANON NO AID 0) = I=) w duro], ued ROO NEOO0OOIN SOC ONO O0NINOISSOWn re © 238 =) 5 3 < = BE = = = a & A = 4 read S NOH AN FOO ANDO == A= AO NISHFOAIAMOOAFON a jo Ae Aq syieod HOFF F FFL OOONFANNONNFANONN— AN S NFO HAN HOOMNANFIMISO ONO HOMO NONANY =] *jasu() Aq sase) ANMIEROF HARA FANN—AA AO = ASI ON NISISO MM - ON vd vt wd vv vv vv — —— 2 . = (01 03 0 ‘2183S NH CONN OO OOMO MNO FHOON NAO = OO | GI w {josuns 03 Isu —- = Ss 5 -Ung)—SSAUIPNO[D) 5 5 U 2 HNO ONOHIN ORO =H ONO OCNMOSFOHNINAN | oH [FO &\[:sanoy jo PMD N GRACO CLEA LAER ES A da ad Bt | Bo —aurysunsg — tv — S| 2a - ! HR | OF b ~ B 3 CT CNMOO FIMO RORINNIOORENIFMOO—FO® | 5 S MIPOPA | Sqwooo Crnooomnowonndnammdtavom= | Sa | o 2 SRUBAY DIM | SNmSeoTSooaARTEre fzmIzagenc (Ls x : = Oo (“ysrupru an w Sa Re) m 03 JYSTUPIN) coconrdntnd8ccorococconnocdBoce on wv a ‘ured [BIOL Ho + Zz - a S (3uad 19d) gn y *£3prun gH 2ANREY $ = @ ~N dwa J, ued Se & I~ r~ 2 3 5 = 4 E.| & J] ° © A z 2 370 TABLE POLIOMYELITIS Tabulated by JuNE Jury. AUGUST. = = s 3 = = = = = s = E re] 2le]2 = Bla g = Ze g n|E(BE|E|E| Cv |, |E|E|B(EE| civ |, |E|E|E|E|2| civ BIS SIS |EE Pls S| El RIE IZ EPEl 2% Ale |B lk|O]|& Ale |a(m]|O|& Ale |a|d|a|& 1 . 1 7 164) 81 1} a2 3{°21] 10; ‘a 47 2 2l 9 3 6 38 3 20 1200 1]. .2 26) 3) 11} "3| 25| .5 44 3. 13) J] 1 14) 4 11 19 9 2 41 4 i 4 2 14) of. 16 5| 12| 5) 26] © (309) 57 5 ol sl 1 220 a 24 6 1 1 -ols 1] 2-121 3 18 6] 13| ..| 20] 10] 1 44 7 or 7 1 15) 0 18 7| 14] 3| 19] 13 49 sl: 1 wisi 3 16] 1] ..|(136) 20| 8| 11] 3| 20| 12| . 46 Ol reh agp] 1 ol 10] 3 17; sl. 35 100 finden LB) ol 3 4448 ..0 3 25] 100 v4] +316) c 7d 43 10[ ia] -2f Ol 3". 18 11 11} 21 15" 4 32 11 j=l aisles 25) 12 12{ 20 12] 41 ..|@ID 30 12 1 yeaa). 3). 230 dsr 33 13 i 130.8] = 18% alia 29( 13] 11020 11] ef ‘1 31 14 i 14 4 1] 16] 3| 2 26| 14] 7] 6| 13] 5]. 31 15; . .s 1syccal a) 8) ar Jley7ay 1ST Asp 10k caf aa)” 500 29 16] | oof A... 1|— 160 17] 1-10; 12] 1 41 Ei LE ay Lael af a6] 32 23 17 137.2] 10; 4] 2 29 17103) L016] 3p 52 24118) Of 1012) 4 26 18 2 oy 2 48; 20 20.2040 452 3119, 16f 51 9] 2]... [((@19) 32 19 3 1 4119] 9] 1] 15] 5 .. 30 20 2 9) 2120 “6] 1/20 6 3 36) 200 13] alla sl 27 21 2 al 21] 8) 2] 20{ 3| 4 371 21] 131 8) 1s). 34 22 2 2123 's|- z| 26] 3] 1j¢220) 301.2% 14] .-{ 16] 16 40 23 7 7 23 121° L426] 51 19 24! .. 7 (26) 7) 23] 12| 1] 16] 4 . 331 24; 11 of 19§ 14 2 29 emer 24) 4 4] 12] 6 2 28] 25{ 100 2] 15] 5] 1 33 25(% 4 oi 4 251 Sy 3} 15] 3 33) 26] 9 2 7 1] 1]|(02 20 260 3 4 .. 75726{.:6] ..-1 19] “ay. 29 27 3 6 i, 9| 27] 14 21 ally al 271 11] sf 7] 3 26 28) 1 9 , 100 280 71 1] 19j.'4f .- 200 280 “3 3 wl 9. 19 29] 1 11 ie 12020] 7] 1] 20] 4] .:[(22%) 32) 20| 4 3]. s{:2 14 30l...1 1] 12 1 14|— 30[ 11] -2|i4] arg 20 30/ 9 24| 10] . 431 31] 10] .. 8] af ‘2 22 31] 16 24; a3) 43 OV 7s] i. 2 87 149| 30(528(/107| 32 846 342| 77|413|171] 19 1,022 () Total for week. 371 IX. ATHS. Date of Death—1916. DE | Now ON | ow CO) restore] Ce ems oe — — =a . . . - 5 a by nl = i =e e | Eg 8 | o | puounony | pAdriiMaaiaap aaa w = 3 T - — — dl Tl =T = E17 swamp | : a fen 2 5 I ~T™ =" ccc] =~. Ur = T= = - ~ 3 ufo fr iT TAN ren jist aabs edt z —_—— rr r= = xuolg fae Tha tie eR figiiet Lalit Ea Nom om Tem RTT a= — — ueeyue . | vi Sls — | =NMY [NON XROO— | NMOS | QO—~NMHW | ONC 4eq | hoe [toto ved —-RANNNNN | ANNE NOHO THX | FNROF, | Or NAM | — NV — | NON «+ - .. — 2 ] a = oh a < -— ~ wr QO + ~ — vol ~ ~ ~ ind TET a TT TTT —- —- tf ovenyma ty ceili] PIT TTT aT & | | | o - a = —- == TT TTT ~ =~ = = su2any Se a a j= = = N= = NN | —— —- —_—— T © = us[yoorg : SC SET R Mr N= — oN — ~ —— NN -— . ad ~ xuolxg . a SERRE ETE EE TN ESRI ET IE SCY Nem —— | = N= —- E | =NFnOS | XOC—=ANMt | INCNNOC— | NMFINOS0 | DO = Leq | rr | m——— A | NANNNNNA | Ne ND | ANIL FNN | OOD [N=ORNXR | XA —~nOX + . aN ON ON vo —— ——— — -— — -+ 5 “© = = — ~ = ~ 4 4 oo hac] hd ° ~ © + — ~ wv w = = - = Zz Z Z : == Hom el reed ss T om «+ Fares Ty TTT eer Oy i 5 J—— | ol aed CONE | cme He | = N—tn— 3 3 | |e | y e N= | NOOCONANTY | FUN | —FOFetN [N NNN — = = uAyjoolg - - . o - wu xuoig — 0) ON] cw ON] — AN — = ——— ON] ON] ~ wid Se - NO | NAO ONS | NOMS | HNN — ueeyURY i es e em | NHN tO [2 - FR | MFO XO | OmNMmFInd | NNOC—N® | FONDS seq em ——_—— | —-—-—-QANNN | ANNAN | TasLe X. Poliomyelitis Deaths Reported by Months—1912-1916. 1912. Jan Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Total Manhattan... A 2 2 2 2 Xs 2 8 9 3 10 7 1 48 Bronx... ....sceis 2 2 J a = os op 5 1 3 3 - 6 Brooklyn. ...... =. he 1 3 3 1 2 2 2 14 Oueens.t. ... .0000 os a 3 = 1 1 re 2 Richmond... ...... bs sie ha New York City. . . 4 3 5 2 3 3 8 9 7 16 9 1 70 1913. Manhattan. ........ 4 3 vd 2 a 2 1 2 6 5 3 1 29 Bony. sues: oivntas vk 2 i vr - 3 ot 5 3 2 2 = os 12 Brooklyn... ...... 5 1 et 2 1 > 1 +e 1 2 = 8 Queens... Li as 1 i cl kis ror 1 i. 2 4 Richmond... ........ i 1 £3 4 1 New York City. . . 3 3 1 ‘4 1 3 7 3 10 9 5 1 4 1914. Manhattan. ........ 3 ies 2 oa hi! 1 1 2 4 J 13 Bronx o.oo dincy oh x 2 on 19 gs 2 7 1 ¥ 12 Brooklyn. .... .. .;.<. 1 2 % 1 ho 1 5 is a 1 6 Oueens......... .i0:3 oh 3% 1 1 1 - 3 Richmond... ....... 24 i 2 = New York City. . . "4 2 4 1 1 3 3 9 6 1 34 ae TasLe X—Continued. 1915. Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. Total Manhattan... ...." ah 1 1 29 1 re 5 1 4 Brong.....5.5 000. 1 Fl as ch 1 1 es a 3 Brooklyn: .... 2... 2 hy 3 1 1 1 5 Queens... ol. i. es 1 t = ii 1 Richmond... c+... 2 New York City. . . 3 1 1 1 2 2 1 2 13 1916. Manhattan... 0: = 1 0 ‘a 7 121 356 164 56 13 8 726 Bronx... 1 oa 1 ve he 31 76 36 24 3 1 173 Brooklyn... 50. 1 1 1 56 498 451 112 30 3 3 1,156 Queens............. 5 i 5 Ere 94 179 46 11 0 oe 336 Richmond.......... 1 33 16 6 1 bi 37 New York City. . . 2 1 2 1 64 777 1,078 364 122 25 12 2,448 €Le ¢ 374 TABLE Poliomyelitis Deaths Death Rate Per 1,000 Estimated June 1st to City oF NEw YORK. MANHATTAN. Total. | Males. | Females. Total. | Males. | Females. Total, All Ages... ...c vues oviidicin ds snsns 2,406 1,408 998 705 402 303 Death Rate. ........cd. eich vimns 1.03 1.20 .85 .64 .73 «35 Under f year... .... .vaivesv. 423 240 183 154 80 74 Death rate 7.93 8.87 6.95 6.31 6.46 6.15 10 2 VALS, ovsicies rc nmnnins s wrinisariaas bun 521 312 209 155 89 66 Death rate. «. ors eins srs nv cuisaminini s ve vs 10.04 11.94 8.13 6.52 7.49 5.55 HOS YATE... caine nels eins elie va we ct 435 255 180 127 72 SS Deathirate. .......c..vuivivnovnts vans 8.91 10.33 7.45 5.56 6.25 4.85 BLO VRAIS. i. ceric sre aes 311 185 126 73 44 29 Death rate... .. coos ss sin vivasinme ss onl 6.43 7.56 5.16 3.14 3.74 2.52 BO. SVeaTS.... ons seps Sirs era Si xe ie 207 136 71 47 33 14 Death rate . ’ : 4.38 5:70 3.04 2.04 2.85 1.22 Total under S Years... ...v visu stars ss sins 1,897 1,128 769 556 318 238 Peathirate. . o.a ei e eedny . ie 7.60 8.94 6.23 4.74 5.38 4.09 SOO VEATS. ... cisos saitivanis as oximimabuin sx vv vin 150 89 61 40 28 12 Peathrate. .. . ..c.ccour ssn 3.38% 3.96 2.73 2.08 2.91 1.24 BO I VeAYS. cocoa rsannnit ss silane 4 il 92 45 47 25 11 14 Death rate 2.06 2.02 2.10 1.32 1.17 1.47 tO Years... a ai da 67 38 29 16 11 5 Death rate 1:53 1.73 1.32 .85 1.18 .33 BIO QD Vears.. iu eB ii i x vs 36 18 18 13 6 7 Death rate .85 .86 .84 3 .68 7d DMO OVERS... occ. ors ca ea es 32 18 14 8 5 3 Deathirate. .....crova ae angsios shines 278 .87 .69 .46 287 .34 Total under 10 years. .....u sv vosivioivns nes 2,274 1,336 938 658 379 279 Deathaate. ne cio ielehnies ema 4.88 5.70 4.05 1.88 3.60 2.67 10to 14 years, inclusive. .......cccvviei inva 62 32 30 11 1 10 15 to 19 years, inclusive... 27 14 13 11 6 5 20 to 24 years, inclusive... 12 8 4 7 S 2 25 to 29 years, inclusive..... 14 10 8 6 2 30 to 34 years, inclusive.:...... 9 3 6 6 1 5 35 to 39 years, inclusive........ 5 4 1 3 3 I 40 to 44 years, inclusive........ : 3 2 1 1 1 4S years and Over. .... civ civ ss disicinirin ns vv vals i oe i Total, 10 years and over..." suvvnins vous 132 73 59 47 23 24 Deathrate. .. ....... civ viamine. Covus .07 .08 .06 .08 .05 .05 375 XL by Age and Sex. Population at Each Age Group. November 1st, 1916. THE BRONX. BROOKLYN. QUEENS. RICHMOND. Total. | Males. | Females.| Total. | Males. | Females.| Total. | Males. | Females.| Total. | Males. Females. 167 96 11 1,147 676 471 330 195 135 57 39 18 .69 «79 .59 1.42 1.69 1.16 2.18 2.50 1.79 1.39 1.83 .91 28 14 14 189 111 78 45 29 16 7 6 1 4.54 4.43 4.65 10.25 | 11.90 8.38 12.98 | 16.41 9.33 8.00 | 14.08 2,23 29 14 15 267 166 101 62 36 26 8 7 1 4.86 4.59 5.14 14.91 :1°18.29 | 11.44 18.75 1 21.60 | 15.837 9.14 | 15.57 2.35 26 14 12 217 126 89 50 35 15 3 6 9 4.73 4.99 4.45 12.95 | 14.87 | 10.74 17:19:./°23.53 1 10.56 18.34 | 14.67 | 21.99 23 16 7 155 90 65 55 30 25 5 5 4.55 6.19 2.84 9.46 | 10.89 8.01 19.09 { 20.40 {| 17.73 6.211 12.585 14 11 3 101 60 41 39 27 12 6 5 1 3.11 4.85 1.34 6.21 7.25 5.12 14.65 | 20.03 9.13 7.49 | 12.41 2.51 120 69 S51 929 555 374 ‘251 157 94 41 29 12 4.41 4.98 3.83 10.83 | 12.78 8.33 16.49 | 20.29 | 12.56 9.82 © 13.90 5.74 10 4 6 73 41 32 22 13 9 3 3 2 2,02 1.61 2.43 4.43 4.95 3.91 6.64 7.76 5.49 6.12 7.02 5.13 8 6 2 44 21 23 11 4 7 4 3 1 1.64 2.47 .82 2.63 2.30 2.77 3.34 2.45 4.21 4.70 6.95 2.39 4 2 2 27 16 11 17 7 10 3 2 1 .84 .83 .85 1.66 1.96 1.36 5.18 4.39 5.94 3.56 4.63 2.44 8 5 3 12 7 S 3 3 1.72 2.14 1.30 37 .90 .63 .94 1.82 4 3 1 15 1 8 5 3 2 .88 1.31 .45 .99 .92 1.06 1.60 1.89 1.29 154 89 65 1,100 647 453 309 184 125 53 37 16 3.02 3.45 2.58 6.63 7.74 5.50 9.83 i 11.67 7.98 6.33 8.74 3.86 5 3 2 26 15 11 18 11 |- 7 2 2 .. S 2 3 9 6 3 2 ol 2 ve Fn 2 1 1 i 4 2 2 =3 oir wr ‘er 2 2 2 2 5 1 1 j! 1 a 2 2 .e ate ae 1 1 2 1 1 vid aR, 2 1 1 13 8 5 47 29 18 21 11 10 4 2 2 07 .08 .05 .07 «09 .06 iY .18 7 .12 .12 33 376 TasLe XII. POLIOMYELITIS. Cases and Deaths in Patients Under One Year. (June 1—November 1, 1916.) Age in Months. Cases. Deaths. Undertmonth...........0 ccs uv 7 3 nh ER 19 13 momo ee a 27 10 SITIONS, ee veniam on sani ots» « 52 17 A IRONENSY. , f.. o o eaa hs 70 24 SHmonths. Lo... a 64 34 OMOAthS ras 98 45 TOMENIEN I. i ve horas iol aba anton 118 45 SOAS... a 104 44 ROS Lh cl Lhe eh 153 52 M0Mmonths. 0... ir ea 149 73 BEmonths. ...... 121 63 otal. iri rid ass 982 423 TaeLe XIII. POLIOMYELITIS. Dearas Unper 10 YEARS, ACCORDING To NATIVITY oF MOTHER. Death Rate Per 1,000 Estimated Population Nativity of Mothers of Children Under : 10 Years. (June 1st to November 1st, 1916.) Death Rate Deaths per 1,000 Estimated By Nativity of Population. Nativity Mothers of Children of Mothers of Child: Under 10 Years. ren Under 10 Years. Austria-Hungary. .........c.couvu'.... 194 1.67 Se 2% alae 13 2.31 British America. ........coovuiven a. 12 1.63 DA ts ov eis de ie 19 1.38 Ranged or en ye Ey 2 .69 (Jet many. LL ee ne ena a 102 2.37 Ireland ee Sr 138 2.28 al i ir ciety 402 1.63 Ruassialand Poland........c........... 381 1.71 SCORE... es in a 12 2.44 ON CH ET a, es ris at 25 2.52 SWIEZEE And ls cr cn ci Ea a 4 2.66 IInitedESthtes. co vo aa 826 2.42 Otherforelpn. . .....oou vhs vnniinn.n. 101 2.69 nkRownt ry... a 23 ee otal, ar bc vir en aha wid 2,274 2.02 377 TasLe XIV. POLIOMYELITIS DEATHS. Tabulated by Place of Death. (June 1st to November 1st, 1916.) Man- The Brook- Rich- |New York hattan. | Bronx. lyn. Queens. | mond. City. Tenements............. 194 45 524 77 3 843 Institutions............ 498 107 400 88 28 1,121 Dwellings. w=... ooo 8 14 221 163 25 431 HOLES torn viva i0ins s 3 a A 1 1 5 ties Ss, vi vey 2 i 2 1 2 6 otal... 00. 705 167 1,147 330 117 2,406 TasLe XV. POLIOMYELITIS. Crry oF New York, 1916. Onset of Cases by Days for Each Borough and for the City. 7 May. JUNE. Jury. 4 S| xR 2 Loh 8.0 a . sre | XK 3 Day 8 8 g ¥ > 8 8 ga v = S E a T 2 of Zt Biel SIBLE] 2 4181S 8 2 4 | © O Month] S | ® | # e g =| = moo s B =| =|" = £ 8 Sli E12 |Z EE st a {2 E13 2) 2 {EE 242 sla|la|a|lR|e|R|Ee|a|la|d|le|2|E]| A |&|&A]| = 1 “F oe rs 2 17 19 1-121, 72 6 8 +98 2 ur oo FE 1 1 2 8 2 58 2 ws 70 3 is - he ar 5 1 1 Toles 3 70 4 2 100 4 le or te. 3 4 For, ve 7 1:18 2 7211 4 107 5 v's vie a air rg, 1 8 | 20 4 3 3 3 105 6 1 ie of 1 to, $1. ie 8 | 14 4 87.1: 11 3 121 7 iy ie oy 2 245 9.122 3 78 8 9 122 8 e 1 iy 1 1 6 ie 1 8122 4 55113 8 104 9 . 1 Sl 1 3 5 “iv 8 | 14 6 67 | 10 7 104 10 ve =r rr 1 8 se 9 | 18 3 771 13.1412 125 11 vit foo x 1 8:1, 1110] 10 6 1:15 4 106 12 a vat oa or Wis, 1.115 7.18 2 57 | 10 6 90 13 ys oe ou 1 10.450 ve 11 §.21 6 68 | 19 6 120 14 or we Jo 1 9 1 1-12) 19 3 65 1° 17;1°13 117 15 vd 470 4 1 ay a 1 27 5 75-116 8 131 16 ih ole a 1 17 oe 4.1.22 | 16 8 82 19:]*11 136 17 es To 1 1 19 +55 «1 20 71.32 2 60 | 17 8 119 18 - vo i iE 3 11:20 + a3 24 | 25 2 80 | 10 3 120 19 or 3 roe ie Le 33, viv] 36: 1:30") 11 60 | 21 7 129 20 af 3 1 4 4-1-0 39 or 21.45% .30 4-21 74 | 12 9 136 21 oa 1... 1 3), 4+24.L or} 271-32 8 7.1 23 9 149 22 ts 1 1 4 $.1:28 2 3 | 38] 41 11 74 | 22 8 156 23 os 1 1 3 =e 31 1 i 351 50 8 85 | 22 2 167 24 oi 3 3 1 1133 2 2139%43 6 78 | 18: 1411 156 25 1 1 2 4 11] 45 oe 2:1 524 40:10 90 | 21 3 | 164 26 1 1 2 6 1:1:80 1 6 | 64 | 54 4 63 | 29 5 155 27 He 4 4 1 3130 3] 52783 7 57] 28 6 151 28 2 Yi 2 6 2 | 46 2 4. {86 1 34 7 81] 28 5 175 29 al 3 1 7 ond 49 3 4 | 63 | 36 9 81 18 7 151 30 1 1 2.51% 2 1.85 0 3 i780) 27-0 aL 78 | 27 2 145 31 1 L {ied or oo ge 69 | 12 110 | 42 4 237 Total 6 24 1 13279 12 [646 | 13 | 36 |786 [893 |184 | 2,275 |517 [197 | 4,066 378 TABLE XV—Continued. AuGusT. SEPTEMBER, OCTOBER. = % ; $8 Padi, stile go] abe Hing gli Day-}-£ 1-2] & BI BE (888 T|lE| 85s TE of 3 on Zilli CO Fife Bil B [iar S ORL 2 Br hab Month) £ =m x = g ve Ae) irl OR = Bry fl Ye BUTE wm g © 8 &| 5 8 E v 5 g| 5 Ss 8 © 8 tsa 8 8 g 5 | 2 5 Sl Ep RE |e EE RES RIG = be m &~ = SlR|d|a|R|e|R|E|ls]&|R]|E 1 70 | 16 119.1 38 4 247 | 36 | 14 | 18 7 2 77 5 4 2 2 13 2 48 1 03 1 33 3 184 | 19 | 12 13; 13 3 | 60 6 6 3 3 18 3 55 7 61 | 34 2 159 | 18 | 10 8 5 "i 41 1 4 3 6 14 4 43 17 84 | 36 1 181 28 3] 10 4 1 43 6 oF 3 1 9 5 373.18 76 | 38 ie 166 | 18 2 a7 7 1] 45 2 4 ois 6 6 57 | 16 56.1 27 1 157 | 15 4 5 8 'e 32 7 1 i 1 9 7 54 | 14 S47 22 3 147 8 4 9 6 1°} 28 4 2 in 1 6 8 32 | 18 51.]°23 5 131 12 5] 13 4 vs 34 1 2s 3 a 4 9 49 | 12 49 | 14 2 126.1 12 2 12 3 1.1230, os 1 3 4 10 53 | 14 59] 26 1 153 | 10 5 6 7 Fo 28 2 1 1 1 5 11 47 1°13 35 | 24 3 122 18 2 3 3 ke 26 1 oe 1 3 5 12 55 | 10 40 | 26 4 135 7 7 5 3 le 22 2 + 2 oe 4 13 51 13 50:19 2 135 7 81] 10 2 ws 27 ve 2 1 te 3 14 47 11 41 19 1 119 | 12 3 8 4 ng 27 Ss ie ve Br 5 15 42 11 29 | 16 1 100 | 15 3 8 4 vii 30 2 iy we 2 4 16 49 | 10 39 | 17 3 118 | 10 3 3 SF.. {23 Ly ‘ve ie i 17 42 | 11 27 | 20 A, 100 9 4 4 3 ee 20 2 i i ¥ 2 18 351 11 48 | 16 1 111 11 6 4 8 0s 29 : § 3 1 3 19 45 13 27 1.24 4 113 7 3 S 3 Xa 18 4 ve 1 1 <0 20 31 8 25 110 2 96 6 2 6 Si. 17 1). 1 1 3 21 35 1712 22 9 1 79 4 3 2 6 ih 13 1 ve ah oF 1 22 33 7 22 8:4. 70 8 6 3 355020 20 TQ. 3 23 33 4 7 10 1 65 8 7 4 4 “ 23 2 e ne os 2 24 29 | 10 20 12 ute 71 12 1 9 4 os 26 1 ne 1 1 3 25 44 7 19 1-17 on 87 6 5 2 1 1 1s 1 A 1 2 4 26 36 3 9.10... 68 6 3 4 1 oF 14 1 2 “s ie 3 27 32 12 22 2 3 71 7 4 6 1 " 18 1 po oy 1 28 31 11 14 | 11 54 67 5 2 3 2 2 12.0 1 2 3 29 19 7 8 3 39 2 1 t 1 vs 5 ‘2 5% re 30 18 4 10 4 36 6 3 SHRI 1] 14 31 21 5 10 6 4%. 5, Ah ey “s, or ie ‘ ve . 0 ve e 1 rs ie Pe 1 May 20 .ie or 0 -e ey: "3 “s . PA J 0 “ey neh ee . ot ou 0 May 27 te we 0 1 ps 7 . “x . 10 2 Tie... “oe ve 31 2 June 3 1 2 3 1 1 . . 1 “in . 3 1 1 3 1 wis & 6 . 2 June 10 a 1 2 1 1 .e s .. 5 PA 1 1 1 .e wy v .. 3 Te 2 3 2 1 a he or . . 2 10 2 June 17 FH 1 Sets, rn ve “e “ 4 “ei “vie wee ie Poe... . 1 2 cis 1 Si). 11% A iv . : 1 G05 June 24 1 3 1 Epes, “e ry r 6 2 5 2 2 2h... . eee 13 3 8 3 3 2) wey “a Pew 0s 19 July 1 3 7 11 4 2 1 1 1 30 2 8 4 5 3 1 . 23 ( y 15 15 9 5 ( 2 1 1 53 1 (1) 1) July 8 11 14 20 9 4 5 1 1 . 65 6 14 14 7 6 2 . ic... 1 1 52 a 28 35 16 10 8 1 2 1 1 5 125 3 1) 1) | (1) (1) July 15 8 14 14 10 4 1 3 1 1 1 3 60 12 18 6 11 1 2 2 3-0. 1 1 3 53 21 23 21 21 9 3 5 4 al 1 2 6 7 124 4 ml@@ July 22 12 27 37 10 5 4 1 2 2 1 101 15 22 19 12 6 7 2 3 2 1 1 90 27 50 58 24 11 11 3 5 5 1 2 9 206 6 (2) Qi i@®lmal@ July 29 24 35 45 26 13 8 5 1 3 3 1 10 174 18 29 33 19 9 9 3 4 3 2 5 134 a 66 79 46 26 18 9 6 6 5 1 15 9 330 13 1) @Q lm] @] Mm Aug. 5 35 42 43 20 14 7 5 5 2 1 8 182 22 33 39 22 10 5 7 3 2 3 6 152 ar ar 83 a 25 a 12 8 4 1 3 14 6 349 9 1 1 1 1 Aug. 12 22 45 32 33 16 17 8 1 5 5 11 195 20 27 32 18 12 9 5 5 4 1 3 136 43 é 64 oF 28 & 3 6 9 5 1 14 12 347 4 1 2) 3) 1 (1 Aug. 19 21 34 39 17 20 9 10 4 2 1 1 16 174 16 24 20 17 10 12 7 4 1 1 9 121 37 3 3 37 3 22 18 3 2 2 2 25 8 311 8 1 2) (1 1 Aug. 26 17 28 23 22 10 8 10 1 3 1 vay 5 128 13 20 31 16 13 5 4 3 4 ve 1 8 118 30 49 56 38 24 13 14 5 7 1 1 13 10 261 5 Sept. 2 12 16 18 13 5 4 8 4 1 2 1 7 * 91 6 16 23 7 2 7 3 3 1 “> 2 3 73 18 32 41 20 1 11 11 7 2 2 3 10 12 176 PEE Sept. 9 12 11 11 10 8 4 4 2 1 1 oi 1 65 4 6 10 11 2 4 1 2 1 wh fn 1 42 16 17 21 21 10 8 5 4 2 ri... 2 1 108 “ Sept. 16 6 11 11 10 2 2 1 wey ae 2 .s ie 45 3 13 4 3 Pe 1 2 . 1 1 1 33 9 24 15 13 6 2 2 2 wes 3 1 1 1 79 . Sept. 23 6 7 6 4 1 Gui en 1 ely a. vn x 31 6 4 5 3 1 “. 1 Sua .e 1 1 22 12 11 11 7 2 6 1 1 we ve 1 1 .. 53 . Sept. 30 2 6 7 3 3 5 a ely 1 3 oe or 28 1 5 4 2 1 Tp... “hs 1 15 3 11 11 5 4 ds wn 1 3 eave 1 1 44 Oct. 7 3 3 4 2 2 1 3 1 vou es os ve 19 1 1 1 5 vay we 2 ee “es 12 4 4 5 7 2 1 5 1 1 ee us 1 Fy 31 Oct. 14 1 2 1 ve “eh 1 “3 1 1 7 as 1 1 1 1 -v Fe er 4 1 3 2 1 1 1 u “ vals 1 1 11 Oct. 21 .en 1 1 “e's 1 1 “ ee 4 1 2 1 2 1 vin 1 8 1 3 2 2 1 1 1 . 1 cou 12 Oct. 28 1 1 2 1 a * 5 ie 2: Len a. “rw 1 3 1 3 2 1%. 1 1 y . . 8 Nov. 1 = ae vx . Bn ie - ih 2 ae Cen) se .e Totals.. 197 | 309 | 332 | 198 | 111 82 61 25 21 19 5 63 | 1,423 148 | 243 | 250 | 165 88 65 39 33 18 7 13 45 | 1,114 351 | 561 | 592 | 374 | 206 | 151 | 102 60 40 26 18 | 110 81 | 2,672 54 TasLe XVIII POLIOMYELITIS, 1916. BOROUGH OF BRONX, . Summary of Cases by Week of Onset, Showing Age and Sex Distribution. MALES. FEMALES. BoTH SEXES. Age | Total | Sex Week Total Total Over| Not | Both | Not Ending. | Under Over| Males.| Under Over | Fe- | Under 10 | Given.| Sexes.| Given. 1 1 2 3 4 5 6 7 8 9 10 10 1 1 2 3 4 5 6 7 8 9 10 10 | males 1 1 2 3 4 5 6 7 8 9 10 June 24 Ft end ¥ tomes x 5 re. aN ii 2 aia 30,00 ev TY os .- ve “ar or 1 1 fae, Eolied, “ee “en . wee 3 July 1 ve 1 2 Fs es ie = %s Vie. on 3 2 1 ee 1 .y wes 1 .e . ee 5 2 2 2 1 ry nn 1 oe 1 9 July 8 3 1 3 4 re 11s o 5, be “rls Z 12 2 2 1 2 3 1 “ i .r .s ‘os 11 5 3 4 6 3 2 Pee. wen v's ve vis 1 24 July 15 .eo 3 6 4 1 2 1 1 1 Fe e's 19 2 2 2 2 2 ey e oy vey 1 Fa 2 13 2 5 8 6 3 2 1 1 1 . 2 1 33 July 22 2 5 9 5 4 1 1 “ne 2 - .“ 1 30 3 3 3 7 3 To}. “ 1 oe v's 1 22 5 8 12 12 7 2 To, 3 “* x 2 1 53 .e July 29 1 7 7 3 1 1 1 ae - on “s 2 23 1 9 6 1 3 2 2 .. 1 .e 2 1 28 2 16 13 4 4 3 3 }55, ia... 2 3 “re 51 « Aug. § 5 7 11 5 8 3 2 2 Zr. oe ra 45 1 6 9 9 3 4 2 Ieee Yass, “r 2 37 6 13 20 14 11 7 4 2 3p . 2 3 85 . Aug. 12 6 8 11 8 7 5 3 3 2 2 ‘ie 2 57 1 4 9 3 4 4 1 1 e's 2 a “i 35 13 12 20 11 11 9 4 4 2 2. Yves 2 5 97 . Aug. 19 4 7 10 4 4 2 2 2 2 on 2 39 7 5 7 5 4 3 1 1 3 1 1 T 38 11 12 17 9 8 5 3 3 5 1 1 2 3 80 , Aug. 26 3 4 6 3 41 4 2]. 1 os 1 28 1 3 2 5 5 1 2 1 1 ie .s 1 22 4 7 8 8 9 1 6 3 1 A 2 1 51 . Sept. 2 4 7 9 8 5 1 ve 2 1 oe a 3 40 1 3 6 5 2 2s 1 2 1 yi... 24 5 10 15 13 7 S71. 3 3 1 1 3 1 65 . Sept. 9 he 1 2}. 4 4 1 ade» » 1 2 15 1 3 4 3 a 1 1 Fann on o- 1 15 1 4 6 3 a 5 2 3... or 1 3 ex 30 . Sept. 16 3 S. lens S 4 1 ve oe 1 1 na: 1 19 1 37. 1 2 eee. 1 1 ee 2 11 4 6-1... 6 7 1 1 1 1 1 - 3 e 31 | (1) Sept. 23 1 5 3 2 2 ee oe 1 «r 2 - 2 18 1 2 3 4 ee ees 1 1 1 as 13 2 7 6 6 2h 1 2 1 3 2 rs S110 Sept. 30 i 1 1 3 1 kis .e - 1 1 se 8 .e 2 3 1 2 i... ow, pe 1 10 sinie 3 4 4 3 1 ben. ee ‘es 1 1 1 1 19 Oct. 7 1 1 1 1 1 1 1 - 7 1 5 4 Seles, 1 “ 14 1 2 6 5 4 1 1 1 -u “ we est 21 Oct. 14 a vie ee iin 1 .- or 1 “ee 1) Gi. . 1 ie 2 > “i 1 EF 1 1 ve we wee 3 Oct. 21 1 .. tes 1 “vo ‘- wie or 1 x oe es . ‘ 1 Oct. 28 we 1 1 1 «a 1 2 1 1 1 . 3 Totals.. 34 61 82 57 47 22 16 13 11 7 2 16 368 30 50 62 53 36 22 12 7 11 5 4 11 303 64 | 111 | 144 | 110 84 44 28 20 22 12 6 27 18 690 (1) 383 TasLe XIX. POLIOMYELITIS, 1916. BOROUGH OF BROOKLYN, Summary of Cases by Week of Onset, Showing Age and Sex Distribution. MALES. FEMALES. Total BoTH SEXES. Age | Total | Sex Week Total Fe- Not | Both | Not Ending. {| Under Over | Males.| Under Over | males.| Under Over | Given.| Sexes.| Given. 1 1 2 3 4 5 6 7 8 9 10 10 1 1 2 3 4 5 6 7 8 9 10 10 1 1 2 3 4 5 6 7 8 9 10 10 May 6 ...c medi i soil Fi at, ran Hrs Irene BE de Boren Rea eR dee fin wet fen dee ol el i es Nee re er} se rh teainn hy setae hits eid dence UA LR Ga Ne Free Sh ee Ye al es i i ee Fee. (1) May 130.0 0 tes. ones Lola oi Yank, fovvins Bond [iene Petointon, vee 1 svn) owew Bde eel. oes x wal veri fae cid Te ie 1 1 be ik 2 (1) May 20]... 2 2 Pons ein tool “0 Fal va’ vE. “ie oe 4 2 re I Fy . “ ne 4 1 4 2:4. 1 ie ie S150 May 27 1 2 1 1 Ox in 5 “oy 2 2 2 1 aes . . .e 7 1 4 3 2 2 we ‘an 12 June 3 4 3 5 4 Ps ge on] 18 2 2 3.15 ” “~ . - a 7 6 7 8 4 18... “ox ein 25 June 10 2 5 9 1 vie 1 1 19 5 6 8 6. ives . i.e fue . os 26 7 11 17 6 1 2 1 45 June 17 6 15 12 5 2 4 o 2 2 48 6 9 12 5 1 1 1 36 or: 24 24 10 3 5 1 2 1 2 on 84 June 24 12 35 23 16 11 6 3 1 1 108 12 24 32 17 8 1 2 1 101 & 59 55 8 19 & 4 1 21 . 2 210 (1) July 1 24 47 50 25 20 13 7 4 2 7 199 18 39 32 27 16 3 35s 2 5 154 43 86 82 53 36 23 10 7 2 20:5. 120s 356 3) (1) @ 1m @ mA | m mn | a July 8 21 56 71 47 24 25 8 8 4 3 1 9 277 20 33 38 32 21 17 7 7 1 2 1 4 183 42 91 1s a & 3 a 5 6 3 13 14 493 | (19) July 15 29 55 52 44 18 18 11 6 6 4 3 7 253 23 38 38 38 27 13 8 4 4 31 7 203 52 a a & 46 aS 20 10 a 7 3 14 15 480 9) July 22 27 59 85 57 17 17 11 5 7 4 5 294 22 42 52 26 16 14 8 5 2 3 1 3 194 a 102 | 138 & 3 32 & 10 10 3 5 8 14 507 (5) July 29 34 67 73 45 24 19 10 5 3 2 2 4 288 30 49 47 37 18 15 10 9 5 3 2 7 232 65 | 116 120 83 a 3 21 14 8 5 4 11 10 535 (5) Aug. 5 29 84 82 58 36 21 14 9 4 6 3 6 352 28 41 69 51 21 16 7 7 4 2 3 7 256 57 1-125'1 152 109 58 a 21 as 8 8 6 13 10 621 3) Aug. 12 26 35 44 33 11 8 7 7 3 7 4 7 192 13 34 23 27 15 10 4 1 6 1 7 141 & 69 67 3 a 19 11 3 13 5 14 8 344 (3) Aug. 19 16 33 21 26 17 7 6 3 2 4 2 8 145 14 13 24 14 15 7 3 Gq... 1 1 6 104 31 46 45 41 33 14 9 9 2 5 3 14 9 261 3) Aug. 26 8 19 19 12 13 4 4 ra... 20. 9 91 7 10 8 8 7 1 2 3 3.) sien 1 1 51 15 29 al 20 20 S 6 4 3 2 1 10 2 344 | .... Sept. 2 4 14 11 10 7 3 1 4 2 4 60 2 7 5 4 3 4 ie 15%, 5 31 6 21 17 14 10 7 1 4 1 2 ean 9 3 95 (1) Sept. 9 5 5 4 4 5 5 24 «an 30 2 35 4 11 6 3 3 1 3 1 1 1 1 4 39 9 16 10 7 8 6 5 1 4 1 1 6 .r Hi... Sept. 16 1 5 6 4 1 3 Mua “aie 2 22 2 6 4 3 2 Sal... 21 cue xq, 2 23 3 11 10 7 3 4 V1. Ber 1p... 4 oe 45 Sept. 23 2 1 2 1 1 en 1 2 1 2 13 1 4 7 1 1 i, Pn “ee PN Pa ale 15 3 5 9 2 2 1 1 2 1 “es .. 2 ats 28 Sept. 30 2 5 3 2 2 pp 1 ve 1 aes 16 1 1 4 1 Pv... : 1 1:8, 2 13 3 6 7 3 Jib cn 2 1 2 .e os 2k vee 29 . Oct. 7 . 3 1 1 “is a +s 1 6 nn vee 2 2 feet vee “se ces aes es len wna 3 Jive 3 2 SF en n'y ees 12 et an ves 2 11 Oct. 14 1 1 1 1 1 - 3 cri) ee Lolo ‘es “ss “es een 3 40. 1 1 21... y-. 1 . cee Si Sn 9 Oct. 21 - nee ie vais es 2 2 v .e “v's ro... we vee i ne 1 ‘ on vivn “ve 1 - “ve . . . 2. 1 ens Sil vans Oct. 28 1 v . 21. eis . v 2 . 1 2 »e vo wow 3:0 ies Totals..| 253 | 553 | 578 | 395 | 212 | 154 87 59 36 30 19 78 | 2,454 211 | 373 | 415 | 305 | 180 | 114 59 49 24 24 12 64 | 1,830 469 | 929 | 1,005 710 | 397 | 276 | 151 | 110 61 55 32 | 142 87 | 4,424 | (53) 5 0s 5d § 5 Ba oy AA RN ity 8 1 Al pie Se Brae, a i XH 385 TasLe XX. POLIOMYELITIS, 1916. BOROUGH OF QUEENS, Summary of Cases by Week of Onset, Showing Age and Sex Distribution. MALES. 3 BOTH SEXES. FEMALES Total Age | Total | Sex Week Total Fe- Not | Both | Not Ending. | Under] Over | Males.| Under Over | males.| Under Over| Given.| Sexes.| Given. 1 1 2 3 4 5 6 7 8 9 10 | 10 1 1 9 3 4 5 6 7 8 9 10 | 10 1 1 2 3 4 5 6 7 8 9 10 | 10 May 13 a vs . . .. . .. . su .v a .s a Zoos ia ‘ oe sy . . . wire - sri] sve May 20 . . .. .. .. .- .. > ve a v3 1%. a ane) 1 be . eh 1 . oe - ve seth vs Looe May 27 . ve i “ . a Pg a os 5 ai Be ls ie soo} vas TR . vs a os % rer} ae i ves) sive June 3 YF 1 ye .e os on e 1 io i vy .e . “ue = 1 . va or oe 5 ae a - 1] . en June 10 ves SRE feed Zs . ie Fe vd i Bo ws Ret yivuie val i x3 Sl a s Cea. oe eds Sp aa, June 17 | .... co pe ce ee fe -. .. ms 1 ie % COA 1 % i... Sai ead) rs . Ee Ae dates be 2lies.. June 24 | .... 1 Ble 1 oe 3.40 2 rs x eros 2 Yo 3 LF sem ies 1 wf fore he ee a 8 July 1 2 2 1 1 2 Your, a 8 1 rie 1 1 ve Se or 4 3 3 1 2 3 bre lon ee, rete ve 12:0 vee July 8 5 4 5 5 8 2 3 oy 1 33 3 3 3 4 2 20... 1 1 19 8 7 8 9 10 4 Sek. 1 cs 2 2 S41 ow July 15 12] 14 6 9 6 3 1 2 53 St peas 8 2 3 4 1 2 47 as Ty 1 8 6 5 1 2 gtr os ve 100 i. (1) July 22 Gi: 141 13] 18 4 3 5 4 1 ex La) 69 3 CER CRE 7 3 4 1 257... 3 2 51 10:0-:20°1 725 1 20°) 11 6 9 5 3, 1 2 31a] July 29 4b 13 27.1 14:10 6 5 2 1). 2 2 86 9 10 20 5 9 3 3 3 2 1 1 5 73 13:0-23 17 11940-10111 8 5 3 1 3 7 5 Looted)... Aug. 5 70 "25:1 26726 a 4 3 1 7 1 S01 128 4] “27:4 "21 [18 ra)" 13 9 6 2 4 1 4 | 118 3s cay eg 17.1 3] 13 9 30. rg 2 9 228 Lg, Aug. 12 CH 91 15] 13 9 6 6 2 11s 5 90 7 nn) 12a 7 8 3 5 1 1 2 3 72 13:] ‘249.20 27% 200 17 9 J 3 2 7 8 2 | 164 v Aug. 19 9. LAT TENE 13] 4 3 2 1 4 1 67 5.06 9 | 14 3 3 4 4 4 2 3 59 16| 17] 20| 24] 14 7 7 7 5 645s 4 4) 131] (1) Aug. 26 7 oy 12 7 3 5 a 1 1 6 50 2 4 3 4 4 Shei] ha a 2 22 10 15| 11 7 8 2] 1 1 5 8 4 76-153 1) Sept. 2 9 6 2 4 1 1 1 24 1 4 4 2 2 3 1 2 19 Laan 4 6 4 1 2 3 1 2 48 | 3) 3 Sept. 9 2 1 2 4 4 1 2 1 17 3 4 3 1 1 2 1 1 1 1 18 3 a 6 7 5 1 1 2 3 1 1 2 1 37 too€a) (1 1) Sept. 16 4 2 1 1 1 1 1 : 11 2 4 4 1 1 2 1 1 16 5 6 5 2 a 2 1 1 1 1 28 (1) 1) Sept. 23 1 1 7 4 2 2 va 1 di os 18 2 1 3 28 2 1 2 is .: 11 3 2| 10 6 2 4 2 1 oe , ¥ .s vs 30 (1) Sept. 30 + 2 2 he vi es ¥ 1 3 5 Lon 1 17) 1 iY. x ie 3 2 1 fm) 1 a . we 1 1 1001.5 Oct. 7 o. 2 3 1 1 2 ey oo 9 1 1 1 = 1 a 4 i 3 4 2 1 1 2.100, 4 : 3 > fu 13 . Oct. 14 . 2 1 1]... . 1 5 1 11... 3 as os 2 an 3 2 Yi... 2s. 8 nn ‘a . 1 a 7 v Oct. 21 oi ee fe 1 1 . 2 SEL 1 1 o 2 hae TRS hae, 2 2 Ea .e ve 4 a Oct. 28 1 1 1 . 3 Bo “ 1 1 2 1 1 vg... 1 1 3 3 Totals. ~62 }a23 a36 | 121 1:75: 35“ 32: 1 "10 | 104743 |. 13 {+23 [0632 46 | 90 | 111 | 88 | 54 | 46 | 33| 25| 16| 10 6| 22| 547 | 110] 214 | 248 | 209 | 129 | 102 | 65 | 45| 26 | 23 | 21 | 45 26 | 1,263 | (8) TasLe XXI. PoriomyeLitis 1916. BOROUGH OF RICHMOND. Summary of Cases by Week of Onset Showing Age and Sex Distribution. MALES. FEMALES. BOTH SEXES. Total Age | Total | Sex Week | Under Over | Total | Under Over| Fe [Under Over | Not | Both [ Not Ending. | 1 1 2 3 4 5 6 1 8 9 10 | 10 [Males.| 1 1 2 3 4 5 6 7 8 9 10 | 10 |males.| 1 1 2 3 4 5 6 7 8 9 10 | 10 |Given.| Sexes.| Given. June 3 - 1 1 .s “i wh e a ie 2 a on vo “a - es ‘is . oie ar 1 1 ly Fo ee Vi) ar we .e ves .s June 10 - i ree. ve x A 5. 2 .s re ire ‘ae a tf on Py reir vee ns Ll g=c. os re 11 Je Co fiee eens June 17 1 = 3 iifseee 1 1 ye os 1 7 ana rhe vn Nore ae as oe “ 1 1 1 3S]-.. 1 Yo... -. 1 Fe cacti June 24 1 ooh, pec 30... aa 4 1 BR CE Be LL 1)... Te 3 1 1 Pie 3 1655 evi): si rte July 1 2 2 4 4 2 If... ix 1 1 17 1]. 1 2 1 2 1.1% 1 9 3 2 5 6 3 3 rn) 1 s *Yeeos 2 July 8 2 3 6 2 1 1 SX eee, 1 1 20 >= 2 3 21% ar... 1 1 13 2 5 9 4 1 5 3 1] 5s 1 2 July 15 2 4 5 7 5 5 2 1 1 1 1 34 1 2 5 4 2 2 1 x: 1 1 2 21 3 61 10: If 7 7 3 1 2 1 1 3 July 22 1 7 9 2 2 gs 1 1 27 4 6 5 7 1 1 2 i 1 1 28 S013] 14 9 3 5 2 1 1 10. 1 July 29 1 5 6 6 3 1 1 1 1 27 1 7 20 ae 1 vi 1 12 1 6-13 8 5 1 2 1 1 Ak ees 1 Aug. S 2 1 2 1 dessa 2a. 3 1 9 ear cee 2 1 3 1 io 7 2 1 2 3 1 5 1 Be 1 wai) Aug. 12 ip 1 5 1 1 Zr. - a 1 11 1 2 is El. 1 + 1 8 1 3 7 1 2 2 1 va po 1 1 Aug. 19 2 Sher 3 1 > i 1 10 us. oq 1 1 va Nore. as 2 Si 2 4 1 3 1 5 - 1 Aug. 26 il. ve) aes 1 va x: 1 1 . vi 1 1 ves 3 I Sas, 1). Zoi vs ve es Sept. 2 ee 1 ve 1 a 5 1 3 2 2 vo: 1 5 SH ny 3 2 Faben is . 1 Sept. 9 1. 1 a on 1 5 3 1 .e 1 |e 1 re 1 s 1 . ve Sept. 16 : x 4a . ve - ve ve . vs or .ic - v ve Sept. 23 “ ie rs Ey es a yi Ac Sept. 30 1 1 1 2 1 1 1 . 1 Totals.. 110 270 47 | 24 24] 29 7 5 6 2 7 9) 181 ‘26:{~ 24 7] 15 7 1 2 2 1 6 | 115 20% 42) 73 48°F 31] 34 14 6 8 2 3113 = Aggie da Tie Ar ad TEREST av. TasLe XXII. Gross Changes. Microscopic Changes. Dura- Place Age tion s : Num-| Name. f Sex. in of Type of Case. Brain.| Cord. | Mes. | Peyr's Brain.| Cord. | Mes. | Peyr's Remarks. ber. Autopsy. Years. | Illness. Node.| Patches. |Spleen. Node. |Patches.|Spleen. 1 R.S:.v.0 W.H.H.| F. | 1 6/12 11 d. Ascending Spinal| +4 | ++ + ? ++ | ++] ++ t= + +} 2 ReXii.os W.HH.IF. | 11/12 7 d. Upper Spinals.. . + + — — =r + ++ fs ae ot 3 GB... VW.PH.|F. 11 7/12 6d. Upper Spinals.. . + + + = + + (+++ + + = 4 M.BE..... W.P.H.| M.| 2 6/12 3d. | Upper Spinals...| + . ? + me + 4 + = + 5 GC. Pu...» W.P.H. | M. 8/12 6d. Ascending Spinal + +4 ? oe + +++ + + + + ++ 6 3. Nin W.P.H.: M.; 2 6/12 3d. Upper Spinals...| ++ | + + wh He ain wl . ne 7 :8.....: W.PH.{ M.| 3 4d. Upper Spinals...| ++ (+++ Ls 3 ap TO, cnn ie ] 8 M. L...... W.P.H. { F. {15 6/12 54d. Ascending Spinal| + + + ? oo epi 1 Sy v oui -+ + .... | Partial Autopsy. 9 B.C...../W.EPH.| M. 7/12 6 d. Ascending Spinal] = + -+ + — wa ge ad res 10 | M.D.....| W.P.H.| M.| 2 6/12 7d. Upper Spinal ....| + + +40 +++) — + + + } : 11 LE. .... W.P.H.} M. 1-2 5d. Upper Spina)... F4+ { FTF | vee’ J woven + eT EE ate .... | Partial Autopsy, Pons & Medulla. 12 G.W..... W.P.H. | M. (21 9d. Ascending Spinal|l + ++ —_ _— _ + ++ nt _ — 13 N.H.....!'W:PH.A FP. | 131/12] 20 d. Ascending Spinal| ++ | ++ + + — vi vine od ae fT sleien Ree 14 Ale. A WB HY TT Maj 2 74 Ascending Spinal| + + ? —_ 2 +++ + “++ — _ + 15 AR... W.PH.{ MI 8 4d. Cortical.» ¥.- ++ ? + +4 i . ol ES TE TR wie fare 16 AL. W.PH. iF 126/12 24. + cove oie + tol vent Pe co ea nies Eo : 17 rN... W.P.H. | M. 8/12 28 d. = es wil ren ers .... | Died of Acute Gastro- Enteritis. 18 MX... | WEPH{F.16 14d. Ascending Spinal| + TL + ? —_— + + + + + 19 E.A.....|W.P.H: | M. [32 5d. Ascending Spinal| + + — —_ + + ++ — —_— + . ‘ 20 H.V......W.P.H: ? M, 7/12 ?7 d. Ascending Spinal| + wie oe + + + {+++ = + =} Diffuse infiltration predominates. 21 8: Gui. W.P.H.] M.! 26/12 3d. Upper Spinal... . + + ? + Fons dhmientil ty cay 22 Ac... «+t W.PH. | F. [4 3d: Upper Spinal = sh = + eu ++ + + ol 23 RaC.:. W.P.H.4 F. [.2 Sd Meningitic. .. + ? —_ + + + —_ — + 24 RS iis WPH.|F [3 3d. + gan — — + Py SERINE Satin 25 S Reiousis Y.PH.|F. 1135/12 4d. 3 eo 5 ? EA ean ee fer Ye 26 J. S000 W.PH.! F. 116/12 4d. le uh: =} + of FS Cvs th Sn eh ane Ry et 27 A WPH. IF, 9/12 6d. Meningitic. ..... + hw — — mt dee a ae Ras Pri 28 M.G.....WPH. | M. 9/12 34d. Upper and Lower Spinal...... = + — + + ine rire Dae er te .... | Lobar Pneumonia. 29 SG. Coo I W.P.H. 1" M. 1-1 6/12 4d. Upper Spinal... . = + ? + wim 2 Sem fi vw SE wn ve 30 PC...... WPH.| Ma{2¢ 6d. Ascending Spinal = — _— + ira A BR eel ena fr Sone 31 S.:Gerv nn W.P.H.| M.| 1 6/12 3d. Upper Spinal....| .... + + -+ wince n By Lier Sa ens 32 K. V.....|At home | M. 3d. Ascending Spinal| + ? det} eee “es «vas wr cratheievan dee en 33 B.V.....!W.PH | M, 6/12 34 Upper Spinal....| + + ES -— — + + _ —_— — : 34 F.S.....; W.LH. 1 M:.12 ? Upper Spinal....| + — — = — eect gals Soa i .... | Moribund on Admis- sion. 35 E. P.....|At home | M. 2/12 13d. Ascending Spinal] = = — — = = + — — — 36 Liens W.P.H. | M. [27 5d. Cortical cose «2s So TF ? ? — Sn aren wr of en meee 37 DEM... W.P.H.| M.| 5 6/12 5d. Upper Spinal....| + =. + + — wane ei) ai 38 JA ..|Athome | M.| 4 3d. Ascending Spinal] + + ? ? + + — — + 39 G. B.....|At home | M. |58 22 d. Meningitic...... + Seat) Sieh na tare ml ha .... | Partial Autopsy. 40 | A. V.....|JAthome | M.| 2 2/12 3d. Upper Spinal....| + + — = + RA “+ — += + L8E 388 TABLE Mortality Statistics, City of New York, 1915 and 1916—Figures Prepared by J Records and on Their City of New York. Manhattan. Subject. 1915. 1916. 1915. 1916. (1)—Number of births, January 1st to Sep- " tember 30th, inclusive.............. 107,100 103,259 49,544 45,987 (2)—Number of deaths under one year of age January 1st to September 30th, incl.. 11,006 10,122 5,534 4,967 (3)—Estimated population under two years of age, January 1st to September 30th,inc. 238,501 244,381 111,174 113,270 (4)—Number of deaths under two years of age, January 1st to September 30th, incl... 14,002 13,238 7,115 6,429 (5)—Infant mortality rate under one year of age, January 1st to September 30th, inc. 102 98 112 108 (6)—Mortality rate under two years of age, January 1st to September 30th, incl... 75.5 72.7 85.6 75.6 (7)—Number of true cases of Poliomyelitis under one year of age, January 1st to September 30th, inclusive........... 9 961 6 326 (8)—Number of deaths from Poliomyelitis under one year of age, January 1st to September 30th, inclusive........... 4 395 2 142 (9)—Infant mortality rate of Poliomyelitis, January 1st to September 30th, incl... .04 3.3 .02 3.1 (10)—Number of true cases of Poliomyelitis under two years of age, January 1st to September 30th, inclusive. .......... 10 1,725 5 531 (11)—Number of deaths from Poliomyelitis under two years of age, January 1st to September 30th, inclusive. .......... 7 886 2 279 (12)—Mortality rate of Poliomyelitis under two years of age, January 1st to Sep- 2 tember 30th, inclusive.............. .04 4.8 .002 3.28 (13)—Number of true cases of Poliomyelitis at 2 all ages, January 1st to September SOth, inclusive. .. 0. oi vie sree 56 8,700 35 2,404 (14)—Number of deaths from Poliomyelitis at | all ages, January 1st to September SOth, inclusive... ......0 0c vives 10 2,290 3 648 (15)—Number of deaths under one year of age, January 1st to September 30th, incl. : Diarrhoeal Diseases. ............. 2,626 1,965 ot 221 1,067 Respiratory Diseases. ............ 2,447 2,293 1,250 1,103 Congenital Diseases.............. 4,252 3,933 2,167 1,819 Contagious Diseases.............. 451 430 251 274 Other Disedses, .,.. 7.00 coivenn. 1,230 1,500 645 701 (16)—Number of deaths under two years of age, January 1st to September 30th, incl.: Diarrhoeal Diseases. ............. 3,090 2,321 1,434 1,243 Respiratory Diseases. ............ 3,754 3,486 1,919 1,651 Congenital Diseases.............. 4,281 3,950 2,179 1,829 Contagious Diseases.............. 1,121 958 663 621 Other Diseases, .... ..civvuvneneen 1,756 2,523 920 1,083 (17)—Infant mortality rate, January 1st to September 30th, inclusive: Diarrhoeal Diseases. ............. 24.5 18.9 24.6 23.2 Respiratory Diseases. ............ 22.9 22.2 25.2 24.0 Congenital Diseases.............. 39.7 38.1 43.7 39.6 Contagious Diseases. ............. 4.2 4,2 5.1 5.9 Other Diseases. ..... vis visenr.... .5 14.5 13.0 15.2 (18)—Mortality rate of babies under two years of age, January 1st to September 30th, inclusive: ! Diarrhoeal Diseases. . 17.3 12.7 17.3 14.6 Respiratory Diseases. 21.1 19.0 23.1 19.4 Congenital Diseases. . 24.0 21.6 26.2 21.5 Contagious Diseases. ............. 6.3 S02 8.0 7.3 Other Diseases. ... .: ices ives 9.8 13.8 11.1 12.7 (19) Total Smber of eoges, January 1st to tember 30th, inclusive: [pe teense nine nane nite ven 36,526 20,946 14,061 10,347 Scarlet Fever.......... 0000005.» 8,8! 4,953 4,147 1,71 Diphtheria fo, ve na 11,808 11,249 5,627 5,278 Whooping Cough. ............... 5,537 7,157 3,140 4,242 (20)—Infant mortality (total number of deaths under one year), January 1st to Sep- tember 30th, inclusive: MEARE, i. civ suns X isivens on nev 148 141 94 107 Suarlet Fever... ..ciceeevseionis 9 4 4 3 DIntheria. . vss esses cranes in 135 169 82 96 Whooping Cough. ......o0v0veen. 169 114 81 68 389 XXIIL the Bureau of Records and Bureau of Preventable Diseases from Their Basis of Computation. Brooklyn. The Bronx. Queens. Richmond. 1915. 1916. 1915. 1916. 1915. 1916. 1915. 1916 36,673 36,332 12,127 12,086 6,966 6,988 1,790 1,866 3,522 3,379 1,019 901 731 691 200 184 84,641 86,780 23,758 24,762 15,185 15,752 3,743 3,817 4,514 4,569 1,279 1,114 858 896 236 230 98 93 84 75 105 99 112 929 71.3 70.2 72.0 60.0 75.6 75.8 84.4 80.1 1 460 1 62 1 97 0 16 i 179 0 23 1 44 0 .03 4.9 0 1.9 14 6.3 0 4.0 2 871 2 104 1 174 0 45 2 441 2 47 1 104 0:0. dS .03 o.7 .01 ) 2.5 .08 8.8 0 5.2 11 4,271 6 632 4 1,113 0 280 3 1,120 3 147 1 319 0 56 975 603 188 144 ! 185 111 S71 40 827 868 206 158 138 129 26 35 1,232 1,269 454 440 309 321 90 84 116 94 49 40 25 18 10 4 372 545 122 121 74 112 17 21 1,145 731 240 164" 209 140 62 43 1,311 1,365 303 230 181 188 40 52 1,244 1.27% 456 440 311 322 91 84 218 100 69 51 41 20 9 537 980 170 241 106 205 23 42 26.6 16.6 15.5 11.9 26.6 15.9 31.8 21.4 22.5 23.9 17.0 13.1 19.8 18.5 14.5 18.8 33.6 34.9 37.4 36.4 44.4 45.9 50.3 45.0 3.2 2.6 4.0 3.3 3.6 2.6 5.6 2:1 10.1 15.0 10.1 10.0 10.6 16.0 9.5 n.3 18.1 11.2 13.5 8.8 18.4 11.8 22.2 15.0 20.7 21.0 17.1 12.4 13.9 15.8 14.3 18.2 19.7 19.6 25.7 23.7 27.4 21.0 32.5 29.3 4.4 3.4 5.6 3.7 4.5 34.4 7:1 3.1 8.5 15.1 9.6 11.4 9.3 17.2 8.2 14.7 12,331 5,334 5,629 3,055 2,902 1,730 1,612 480 2,439 1,926 1,228 662 722 456 170 199 3,637 3,137 1,792 1,276 623 608 129 238 1,471 1,613 417 772 295 227 204 303 31 24 12 7 6 3 5 0 3 0 0 1 2 0 0 0 39 39 11 i 1 9 2 4 43 31 26 11 16 4 3 0 390 TasLe XXIIT— City of New York. Manhattan. Subject. 1915. 1916. 1915. 1916. (21)—Mortality rate from all causes, based on estimated population, under two years of age, January 1st to September 30th, IEIuSIVe. ee ea 14,002—78.5 13,238—72.7 7,115—85.6 6,430—75.5 Measles... vies ain niente: ve 415 353—1.92 274 273—3.21 Scarlet Fever, ..... 00 viicrin vs 50 16— .09 31 11— .13 Diphtheria... Xz. 0 coniivann ie 275 261—1.42 146 153—1.80 Whoopitig'Cough. ..o "uous: os 391 335—1.83 222 184—2.17 (22)—Infant mortality rate, June 1st to Sep- tember 30th, inclusive... .......... 5,227—111.3 4,665—105.4 2,528—115.7 2,267—104.1 (23)—DMortality rate for babies under two years of age, June 1st to September 30th, SHelUBive, od i re ans eae rvs 1 wr 6,610—82.8 6,280—76.9 3,357—90.4 2,946—77.9 (24)—Infant mortality rate, June 1st to Sep- tember 30th, inclusive: Diarrhoeal Diseases. ............. 2,004—42.7 1,362—28.9 906—41.5 732—33.6 Respiratory Diseases. .... 951—20.2 705—14.9 360—16.5 325—14.9 Congenital Diseases. . 1,574—33.5 1,646—34.9 917—42.0 766—35.2 Contagious Diseases. 199— 4.2 147— 3.1 113— 5.2 91— 4.2 Other Diseases. ..........c....... 499—10.6 1,116—23.6 232—10.6 354—16.2 (25)—Mortality rate of babies under two years of age, June 1st to September 30th, inclusive: Diarrhoeal Diseases. ............. 2,377—29.8 1,652—20.2 1,066—28.7 870—23.0 Respiratory Diseases. ............ 1,290—16.2 1,174—14.4 618—16.6 531—14.0 Congenital Diseases.............. 1,667—20.9 1,652—20.2 924—24.9 770—20.4 Contagious Diseases. ............. 459— 5.7 322— 3.9 288— 7.7 205— 5.4 Other Diseases. .................. 817—10.3 1,483—18.2 461—12.4 573—15.1 391 Continued. Brooklyn. The Bronx. Queens. Richmond. 7 1915. 1916. 1915. 1916. 1918. 1916. 1915. 1916. 4,514 4,569—70.3 1,279 1,114—60.0 858 897—106.2 236 230—80.3 84 56— .86 32 16— .8 12 7 13 1 14 2— .03 1 2— .02 4 1 vs 63 56— .86 38 28— 1.51 23 17 5 7 116 104— 1.60 39 34— 1.83 12 12 2 1 1,682—104.4 1,574—116.2 473—90.2 389—72.7 377—126.3 341—110.8 117—148.9 94—120.5 2,100—74.3 2,245—77.3 582—73.3 488—91.3 442—87.1 476—90.4 129—103.2 125—97.3 743—46.1 423—26.1 148—28.2 87—16.3 152—50.9 86—27.9 55—70.0 34—43.6 472—29.3 292—18.0 58—11.1 42— 7.8 49—16.4 36—11.7 12—15.3 10—12.8 282—17.5 515—31.8 199—37.9 193—36.1 136—45.6 135—43.8 40—50.9 37—47.4 56— 3.5 33— 2.0 17— 3.2 13— 2.4 10— 3.4 9— 2.9 3— 3.8 1— 1.3 129— 8.0 621—38.3 51— 9.7 54—10.1 30—10.0 75—24.4 7— 8.9 12—15.4 892—31.5 529—18.2 188—23.7 104—12.6 172—33.9 112—21.3 59—47.2 37—28 8 513—18.1 494—17.0 82—10.3 68— 8.2 63—12.4 64— 12.2 14—11.2 17—13.2 368—13.0 516—17.8 199—25.1 193—23.3 136—26.8 136—25.8 40—32.0 37—28.8 103— 3.6 70— 2.4 39— 4.9 27— 3.3 23— 4.5 16— 3.0 6— 4.8 4— 3.1 224— 7.9 636—21.9 74— 9.3 96—11.6 48— 9.5 148—28.1 10— 8.0 30—23.4 U.C. BERKELEY LIBRARIES MAL, Ln C022344953