~18 PUBLIC HEALTH. MA~cH,

EPIDEMIC POLIOMYELITIS IN Batten and John Thomson* share the same WESTMORLAND,* view. This being so, Batten prefers the term SUMMER AND AUTUMN, I9II. " polio-encephalo-myelitis," or as a neater and By W. E. HENDERSON, M.A., M.B., Ch.B., D.P.H., more portable term "epidemic paralysis." Couuty Medical Officerof Health, Westmorland. To him we are indebted for a valuable analysis of the different types of polio- encephalo-myelitis. These are :-- MID much that is uncertain as to the causal I. A localized paralysis of one or more A agent and the method of spread of poliomyelitis, there are certain undoubted facts limbs. 2. An ascending paralysis, often rapidly confronting the health officer, calculated to fatal owing to involvement of the make him face new problems and think in new respiratory centres. categories. In the matter of poliomyelitis most of us are 3- An acute ataxia. 4- A paralysis of one or more cranial nerves. at the stage when we are "marshalling our facts and court-martialling our fictions." 5. Hemiplegia. 6. Symptoms of meningitis. What are the facts ? I. Poliomyelitis is an acute, infective disease, 7. An acute mental defect. 8. A type of case in which pain, especially which appears in epidemic form. There can, on movement, is the most marked I think, be no doubt about this. feature--so-called neuritis. In his comprehensive and exceedingly able Paper on the Epidemiology of Poliomyelitis in Most of these types are exemplified in the the current number of "Brain," Batten+ has Westmorland epidemic. collected the records of over 7 ° outbreaks of 3. TheVirus. Landsteiner, Popper, Levaditi, poliomyelitis, involving 17,5oo cases. These Flexner, Lewis and Gordon have shown that the records cover a period of 29 years, from 1881-- disease can be transmitted from man to monkeys 191o , and embrace many lands. The first by inoculation, and from monkey to monkey; records of outbreaks come from Sweden and that the virus is not killed by glycerination, Norway, but every European country has suf- and that it will pass the finest filter. The fered, while the United States of America have organism has not been cultivated in vitro, has been visited by very severe epidemics indeed. not yet been stained, and has not come within Even Australia, Cuba, and the Island of Nauru the range of the most powerful microscope. in Melanesia have been invaded. The virus can be obtained from the mucous 2. The clinical picture of poliomyelitis is membrane of the nose of a monkey which has changing. It is changing for the worse. suffered from the disease, and that even six Until quite recently the text-books taught months after the date of infection. us that the characteristic victim of polio- It is only possible to infect an animal byway myelitis was a child of two or three years of age of the nasal mucous membrane after injury to who, put to bed, perhaps fretful and feverish, was ~his membrane. found next morning with a flaccid paralysis of The virus is most readily obtained by emul- a lower limb. And so they'called the disease sifying the brain and spinal cord of a human "infantile paralysis." But this term must being or of a monkey dead of the disease. now be outlawed from medical nomenclature. Successful inoculation of the virus may be Adolescents and adults are now being affected, made into the brain, intraperitoneally, in- and they do not always survive. travenously, or by application to the injured Still has shown that' in some cases of polio- nasal mucous membrane. myelitis-- THE WESTMORLAND EPIDEMIC. "there is a profound constitutional disturbance sug- (Cases arranged in chronological order). gestive of some acute infective disorder. The facial In this epidemic the first case occurred on palsy which some cases exhibit proves that parts at least July Ilth, i9ii,--the last case on Octo- as high as the pons may be affected, and if ber I4th, 1911. the disease may produce inflammation of the grey matter at this level, there seems to be no reason why it should The disease first made its appearance in not produce it also in the grey matter of the corte~." i~ epidemic form in July, 1911, at Staveley, a village of some 65o inhabitants, situated on *Read before the North Western Branch of the Society of Medical Omcers of Health, December 15th, 1911. the main Kendal-to-Windermere Road. See also "Public Health " No. ~, voh xxv, p. 51. Common Disorders and Diseases of Childhood. G.F. Still. Oxford * Cliniaal Examination and Treatment of Sick Children, John Medical Publications, pp. 596-7. ; Thomson. Green and Sons, 190t~. 1912. PUBLIC HEALTH 219

Through the kindness of Dr. Innes Dick, of September 3rd, 1911 :--No improvement. Staveley, I am enabled to furnish the following CASE 4, Staveley, August i31,%, I911 :-Dr. Dick was account of the beginning ofthe epidemic, and called in to see an infant A. B., male, aged tI~ as the first cases are typical of many more, I months, residing at Kentmere, 4 miles from the other cases. The following history was elicited : quote Dr. Dick's reports in full :- Mother stated that child had been cross and CASE I, Staveley, July izth, I9II.--Dr. Dick, of irritable. She thought it was a sign of teething. Staveley, was called in to see F. B., male, aged Symptoms observed: Child fretful and irritable, IO, of Main Street, Staveley. The following gums inflamed, no fever. Continued so until history was elicited :--Child had measles in August 2oth, 191I :--On this day it seemed to April, 1911, and. never seemed to recover fully. take little notLce of anyone, though quite conscious July Ilth, I91I :--Went to bed with a severe and taking its food. headache ; vomited same evening. August 23rd, I911 :--Child unconscious. Re- July I2th, 1911 :--Vomited whenever he swal- traction of head, stiffness of limbs, pupils widely lowed anything. The following symptoms were dilated, non re-active to light. found :--Temperature lO 3 ; pulse i2o. Greatpain I911 :--Condition same, pupils non complained of in back of head and in neck. August 241h, re-active to light. Breathing stertorous. Child Child lying in bed on his left side with his neck unconscious. Pulse was ever slow. Head retrac- markedly retracted, his limbs flexed at elbows, hips tion marked. The left side of the body seemed to and knees. He screamed when he was moved be more rigid than the right, though the mother about. Pupils normal. No ear trouble. During stated that when lifting the child the whole body that night he was delirious, and on the following seemed more rigid than usual. day the symptoms were greatly aggravated. August 251h, 1911 :--Same, but that night had a There was a left-sided facial and upper arm a general convulsion. Temperature IO4. No paralysis, with great stiffuess at the neck. temperature until convulsion. Breathing was stertorous. August 261h, 19Ii :--Much worse. Tempr. IO2. July I4th, 1911 :--The child was better to some August 271k, 1911 :--Child died. Certified extent and the temperature was falling. posterior basal meningitis. July i51~ , r9II :--Temperature normal, and the condition slowly improved, save paralysis. CASE 5, Kendal, August i6th, i9ii :--Br. Brumwell, of Se~btember 2rd, 191I :--At the kind invitation of Kendal, attended a male aged one year. Paraly- Dr. Dick we examined the child together, and sis of lower limbs. Much constitutional distur- found left facial paralysis and a certain amount bance. of weakness of the shoulder girdle muscles. Left CASE 6, Pooley Br., August I7th, 1911 :- Dr. Inglis, of arm raised with difficulty above the head. Penrith, attended name infant aged 9 mont-hs. (The mother states that the temperament of the Symptoms resembling Case 3. Died August 2ISt, child is quite altered. He is irritable and dis- 1911. Certified posterior basal meningitis. obedient.) CASE 7, Kendal, August 22•d, I9II :--Dr. McCallum, December I3th, 1911 :--Facial and upper arm of Kendal, attended female aged 28. Type, palsy still present. Considerable improvement symptoms of meningitis with acute ataxia. Partial has taken place. and tedious recovery. CASE 2, Staveley, July I2th, I911 :--Aboy. I. L., aged CASE 8, Old Hall, August 241h , I911 :--Dr. Fuller, of io, living some 2o yards away from Case I, eom- Milnthorpe, attended male aged 1I years. Type, plained of pain in the back of the neck and down lower limb paralysis. Paralysis persists. Im- the spine and in the legs. Mother noticed that provement. his face got very red. The following were the symptoms found: All spine tender; normal CASE 9, Underbarrow, August 261h, 1911 :--Dr temperature ; full bounding pulse. Symptoms McCallum, of Kendal, sent for through the night looked like those of heat stroke--the weather at to see a girl 8 years of age, who was screaming this time was excessively hot. The child was put with pain in her head. Symptoms very like cerebro-spinal meningitis. There was a blotchy to bed. July 13th, 191I :--He could not use his right purpuric rash on trunk and arms. leg. There was complete motor paralysis of the August 3oth, 191I :-I examined this case with right leg ; loss of knee jerk. He had not emptied Dr. McCallum. Child lying placidly in bed, quite his bladder for 24 hours. The paralysis gradually conscious. On attempting passive movements of improved. limbs child cried piteously. Head retraction: SefJtember 3rd :--On examination we found that nystagmus. Motor paralysis of both lower limbs. there was considerable disability in the right leg, Temperature IOO. Lumbarpuncture. No meningo- the boy dragging the limb. There was no wasting cocci-- L.G.B. Lab. of the muscles. CASE io, Underbarrow, August 3oth, 1911 :--In same December 13th, 191I :--Certain amount of para- house as Case 9, male (a twin), aged IO months. lysis still persists. developed an abortive attack. C.~sI~ 3, Staveley, July ilth, 19II :--Dr. Dick called in to see an infant aged 3 months, male, residing CASES II and 12, Natland, August 261h, 1911 :--Dr. in Staveley, because mother thought that its right Sturridge, of Kendal, attended two cases at Nat- arm was dislocated at the shoulder. On exami- land (2 miles south of Kendal), a male aged 9 and nation, complete motor paralysis of the right arm a female aged 12. Dr. Sturridge reports "both was found. were taken ill within a few days of one another, 220 PUBLIC ILEAL TZ1. MARCH,

both with cerebral as well as spinal trouble ; both and legs. Left leg and left arm paralysed. Could had sore throat and headache. One, the girl, is talk rationally. Tongue projected straight. Pupils still paralysed." contracted. Epilepti-form convulsions lasted all CASE 13, Kendal, August 26lh, 1911 :--Dr. McCalluln night. Died 5 a.nl. attended male aged 5 years. Type, acute taxia ; CASE 3o, Burneside, .S'e~tember4fh, 19I I :--(Burneside fell during play ; had to be carried home. Parent is near Kendal). Dr. Cochrane (for Dr. Riddell) thought due to wading in water. Flaccid paraly- attended male infant, aged 2 years. Type, right sis of both lower limbs. Paralysis persists. facial and right upper arm paralysis. Recovery. CASE 14, Kendal, August 27~]z, 1911 :.--Dr. McCallum CASE 3 I, Kendal, September 6tk, 1911 :--Dr. McCal- attended male aged 7 years. Type, lower limb lum attended female aged I year 4 months. Type, paralysis. Recovery. meningitis. Recovery. CASE 15, Crooklands, A~tgust 27th, 19II :--Dr. Black CASE 32, Milnthorpe, Seftember 6Nz, 1911 :--Dr. (for Dr. Purves, Milnthorpe) attended male, aged Black (for Dr. Purves, Milnthorpe) attended female 7 years, attending same school as Case 8. Type, aged 6 years, who died September ilth. Death lower limbs paralysed. Improvements marked, certified posterior basal meningitis. certain amount of paralysis persists. CASE 33, Gatebeck, Se~tember7Nt, 1911 :--Dr. Fuller, CASE 16, Kendal, August 2811~, i9tt :--Dr. Sturridge • Milnthorpe, attended male aged 4 years. Type, attended male aged io. Type, lower limb paralysed. lower limb paralysis. Much improved. Still Complete recovery. certain amount of paralysis present. (Dec., 1911.) At this juncture, Dr. R. Musgrave Craven, CASE 34, Crook, 5'efilemker 7th, 1911 :--Dr. Dick, the medical officer of health for the West- Staveley, reports as follows :--male, aged I I years, suddenly seized with headache, vomiting, fevered morland Combined Districts, circularised all pains in back. Attends same school as Case 37. the doctors practising in Westmorland, seeking Great pain on passive movement of lower limbs. for information on past and present cases. Decubitus flexed position. Difficulty with lnicturi- CASES I7-23, Kendal, August 281,~, 191I, et seq. :--Dr. tion, priapism marked. Temperature IOO. Irri- Manning about this time attended about seven table, intelligence clear. Recovery. cases in all. Four naales, ages ranging from 3 years CASE 35, Kendal, Se2Member 9t/z, 1911 :--Dr. Cockill to 19 years, 3 females, ages from 2 to IO years. attended a female aged io years. Type, lower Type, spinal. Three males and two female still limbs paralysed. Dropped foot. Complete re- paralysed. covery. CASE 24, Kendal, Mugust 291h, 191i :--Dr. McCallum CASE 36, Kendal, Se;blember 9N6 191I :--Dr. Cockill attended male aged i½ years. Type~ meningitis. attended a male aged 3. Complete motor paraly- Recovery. sis of lower limbs. Paralysis persists. Consider- CASE 25, Kendal, August 291h, 191I :--Dr. McCallum able improvement. attended naale aged 6 years. Type, lower limbs CASE 37, Crook, Sefitember Ii///, 1911 :--Dr. J. paralysed. Paralysis persists. Cochrane Henderson, Windermere, reports as CASE 26, Kendal, August 3ist, 19JI :--Dr. McCallum follows :--male aged 9 years, complained of acute attended strong healthy male, labourer, aged 2z. headache and pain in back, of nausea and high Returned from work because of violent headache, fever--this on September Ilth. giddiness and unsteady gait. Patient removed to Dr. J. C. H. called to see the boy on Sept. I3th. sanatorium. Lbwer limbs paralysed. Developed Temperature lO3, pulse 12o. Paralysis of both girdle pains. Very marked tynapanites. Retention lower linlbs. Kernig's sign present in both limbs. of urine for 14 days; abdominal muscles paralysed. Retraction of head marked. Patellar reflexes Rectal sphincter weak. Extremely ill. Kernig~s sign abolished. marked. Tache c6r6brale. Oculo-motor paresis. SeiMember I4Nt, 19II :--Temperature IOl, pulse Repeated lumbar puncture. No meningococci-- 14o. Marked prostration. September ISth, L.G.B. Lab. 5.15 p.m.-=I saw this child with Dr. J. C. H. CASE 27, Kendal, August 31st, 191I :--Dr. Leeming, Temperature sub-normal, pulse i2o, soft and of Kendal, attended male aged 3 years. Child unequal. Intelligence clear. A little stiffness of suddenly seized with very severe headache and neck. Pupils equal, dilated slightly, reactive. vomiting. I saw this case with Dr. Leeming on Prostration extreme. Breathing shallow and September 2nd--the child was extremely ill. laboured. Respiratory muscles seem to be in- Unconscious ; head retracted ; paralysis of lower volved, abdominal reflexes abolished. Complete limbs ; nystagmus. Peculiar odour from body. motor paralysis of lower limbs, save for slight Child died same night. Lumbar puncture. movements of toes of right foot and faintly of left. Clinical Research Lab. -- meningococci found. Sensation unimpaired. Grave prognosis given. Death certified cerebro-spinal meningitis. Child slowly recovered, both limbs still partially CASE 28, Kendal, Se2btember 3rd, 1911 :--Saw with paralysed. (December, 1911.) Dr. Cochrane (acting for Dr. Riddell, Kendal) CASE 38, Stavely, SexOtember I2t]1, 1911 :--After an male aged 4. Type: Twitchings of facial interval of two months another case occurred in nauscles, and of right arm. Pain on passive move- Staveley, which I saw along with Dr. Dick. ulents of limbs. Severe headache. Recovery. Male, aged 4 years. Type, both lower limbs CASE 29, Kendal, Sefilember 3rd, 1911 :--Dr. Brumwell paralysed. No improvement. (Dec., 1911.) called in to see male aged 59. Had been ill for CASE 39, Milnthorpe, Se;blember I4/~, 1911 :--Dr. some days. Temperature lO3, pulse good. In- Fuller attended female aged 14 months. Type, tense shooting pains down muscles of neck, back lower limb paralysis. Recovery. i

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CASE 40, Witherslack, September 151k, 1911 :--Dr. No spasm of neck or face muscles, No rigidity of Black (for Dr. Purves, Milnthorpe) attended neck. No retraction of ribs. Diaphragm acting. female aged 6 years. Type, lower limbs para- Arms move all right voluntarily, some curious spasms lysed. Recovery. of fingers. CASE 41, Storth, Seiblemker I717¢, 1911 :--Dr. Black Leg's ~aralysed, except for power of rolling out. attended female aged 4 years. Type, lower limb ? psoas action. paralysis. Recovery. patella and ;blanlers reflexes absent. No numbness CASE 42, Stainton, Sel)tember I7th , 191I :--Dr. Black or anmsthesia or hypermsthesia. attended male aged 8 years. Lower limb paraly- Kernig's sign Y--Leaning forward produced cramp sis. Complete recovery. in the thighs. CASE 43, Kendal, September 247~, 1911 :--Dr. Cockill Pain. Some headache, not severe. Some pain in reports that he attended a male aged 17. Date back. of onset of disease September 24th, 191I. Tern-. Her fear of suffocation owing to difficulty of breath- perature lO3, slight headache, vomiting, hyper- ing masked all other symptoms. aesthesia about neck. Kernig's sign well marked. She died at 5 p,m. same day, less than 5 hours from Chief symptom great difficulty and terror in deglu- the time that I first saw her. tition. (Clinical picture very like rabies). No Examination of cerebro-spinal fluid by Dr. Mervyn paralysis of limbs. Died September 26th, 1911. Gordon confirmed diagnosis of poliomyelitis." Except for drowsiness 3 hours before death, the CASE 45, Crook Road, near Kendal.--Dr. Cockill patient's intelligence was quite clear. attended male aged 8 years. Child complained CASE 44, Grasmere, Se#tember 25173, 1911 :--Dr. Hough, of severe headache and pains in limbs. I saw Ambleside, kindly furnishes the following record : this case with Dr. Cockill on September 3oth-- condition as follows :--Extreme irritability. In- A young woman of gentle birth and comfortable circum- tense photo-phobia. Lying curled up in bed. stances, living at Grasmere, aged 24, one of a strong, Complaining of headache. Temperature lol. active, athletic family, herself robust and never a day's Flexion extreme at knees. Screams on any illness of any consequence, attempt at examination being made. Intellect "On Friday, September 22nd, 1911, went a long walk clear. No head retraction. Marked myo-tatic over the fells, got wet through, came home, had a hot irritability. Type, neuritis. Complete recovery. bath and chahge. Felt none the worse. CASES 46 and 47, Kentmere, September 29th, I9rI :- " Saturday, September 23rd. Felt as usual. A pour- Dr. Dick attended male aged 8 years. Transient ing wet day, so stayed in doors till evening, when she symptoms of poliomyelitis. Left leg weak for went a walk and again got wet through, again a hot several days. Complete recovery. Brother of bath and change. Played bridge all evening, her case 44 (living in same house), aged ro years, had sister lkouyM she looked tired. similiar symptoms. " Sunday, September 24th. Went to church and spent CASE 4 8, Hollin Hall, near Ky. Lonsdale, October I4th, the day as usual, not feeling ill, I9Zt :--Dr. Mathews, of Kirkby Lonsdale, attended " Monday, September 25th. Came down to breakfast, a male aged lO. Type, facial and arm paralysis. but felt and looked bad, so went back to bed. Com- Paralysis persists. plained of aching pains all over. Some headache and Here the epidemic ended, so far as West- backache. A doctor staying in the house saw her and morland was concerned, but Dr. Mathews, thought she was in for influenza, and gave her some M.O.H. for Kirkby Lonsdale, informs me that aspirin and pl~enacetine, and I think a subcutaneous he attended three cases in Lancashire, just injection of morphia. She had a bad, painful and restless night, and seemed worse on over the Westmorland border, at Sillet Hall. "Tuesday morning, September 26th. At 12 noon I Of these, two cases occurred in the same saw her for the first time. Found her in bed. Looked house--a female aged 12, where the cranial extremely ill. Far too bad for a thorough examination. as well as the spinal nerves were involved; At 2 p.m. Dr. Brooksbank of Windermere kindly saw and a boy aged 5 with lower limb paralysis. the case with me. She was propped up in bed with a These cases were first seen on September 26th. most anxious expression, face dusky, lips blue, skin generally dusky in patches showing venous congestion. Both are still paralysed. Again on October 6th Using all her extraordinary muscles of respiration and he saw (at Docker Park, Arkholme) a boy aged alae nasi. Extremities cold and clammy. No rash. 6. Type, lower limb paralysis. Tache cdrdbrale present. Dr. Mathews makes a very interesting state- Eyes.--No ophthalmoplegia, but pupils unequal. The ment with regard to his cases. He says "In right, though turned to the light, dilated. at least two of the houses (farms) I have been ~ars.--Hearing normal. Wose,--Slight epistaxis yesterday. struck by the fact that there have been many Teml~erature.- 100' 9. unaccountable cases of loss among the stock." Res2Mralion.-- I rregular--32-58. DOUBTFUL CASE. Pulse.--I2O, Soft, compressible, regular. Heart I have said the epidemic began on July t2th, sounds feeble, no murmur, not a bad impulse. 1911, but there died at Garlands Asylum, Ton~ue.--Dirty patchy fur, not dry. Sordes on teeth. Swallows jerkily. Carlisle, on July 6th, 1911, a labourer of ~ladder and Rectum normal. Kendal, aged 45 years. Death was certified 191'2.. PUBLIC HEALTH. 9,23

as due to cerebral meningitis. The history of The following are some of the theories :-- this case is very remarkable. On July 2nd, I. Bathing in running water, pure or impure. 1911, he was transferred from the County 2. Consumption of foreign flour. Hospital, Kendal (general hospital), to the 3. Consumption of sweetmeats infected by Kendal workhouse, as he showed signs of the house fly. mental disorder. When at the poorhouse he 4. Exposure to heat. developed acute mania, was transferred to 5. Exposure to damp and cold. Garlands Asylum, where he died in two days' 6. Over-exertion. time. 7. Schools. At the post-mortem examination death was 8. Vermin-borne. found to be due to meningitis, death being 9. Caught from lower animals. certified as being due to cerebral meningitis. IO. Dust-borne. SUMMARY. Are there amongst these ten conjectures any Total number of cases (including doubtful which will fit the facts ? case, 3 cases certified as posterior I. Schools.--In some of the epidemics recorded basal meningitis, and one as cerebro- by Batten the school has undoubtedly been one spinal meningitis ...... 49 of the contributing causes. Total number of deaths ...... 8 In the Westmorland epidemic in only two Mortality per cent ...... 16" 3 schools were two scholars affected, besides the Total number of males ...... 36 epidemic was in full swing during the summer Total number of females ...... 13 holidays. Ages :- 2. Vermin.--Our answer is in the negative. Under 2 years ... 8 Io years5 ... 7 The disease invaded many homes where vermin 2 years ...... 2 Ii years ... 3 are never seen. 3 years ...... 4 12 years ... 2 3. Caught from th~ lower animals.--Save for 4 years ...... 4 17 years ... I Dr. Mathews' interesting observations at the 5 years ...... I 19 years ... 2 Kirkby Lonsdale farms, I am not aware of any 6 years ...... 2 22 years ... I undue mortality among lower animals in the 7 years ...... 3 24years ... I affected areas. And yet how very like rabies 8 years ...... 3 28 years ... I is the virus itself and, in fatal cases, the symp- 9 years ...... 2 45 years ... I tom complex. 59 years ... r 4. Bathing and wading" in running water.- Hitherto in sporadic cases this has been a well- No. with one or more limbs paralysed .... 37 known theory. Dr. Dick, of Staveley, tells me No. with ascending paralysis ...... 3 most of his cases were bathing and wading in No. with acute ataxia symptoms ...... 3 the icy waters of the Kent as it flows through No. with paralysis of one or more cranial nerves 6 Kentmere. No. with symptoms of meningitis ..... IO 5. Dust-borne.--This theory has some stout No. with symptoms of acute mania ...... I defenders. In the Westmorland epidemic I No. of cases still paralysed (Dec. ISth , 1911) 19 must confess that when one considers the Two cases occurred in the same house in geographical distribution of the cases one is four instances. struck with their close'proximity to much Two scholars affected in the same school in frequented main roads. The vast majority two instances. occurred in a narrow belt of country lying to Practically all who had paralysis of one or the west and south of the county, a tract which more limbs complained bitterly of pain on embraces the main roads from the south to the passive movement of the affected limbs. Lakes. Viewing the epidemic as a whole, this symp- Are there carrier cases ?--This epidemic left tom was the most universal and striking feature Staveley free for two months and re-commenced in the clinical picture. there. As touching this fascinating subject of SOME CONJECTURES AS TO METHODS OF carrier cases we can but vaguely surmise. The SPREAD. more one investigates this strange and, very Theories as to the way this disease spreads tragic disease the more perplexing seems the are legion. They range from French mariners solution of its epidemiology. It is all so intan- hawking Spanish onions, to the house fly. gible-as yet. For instance, while conducting 9,24 PUBLIC HEALTH. MARCH,

medical inspection at Warcop--a little village SOME EXPERIENCES IN CONNECTION tucked away in deep pastoral solitudes between WITH EPIDEMIC DIPHTHERIA.* Appleby and Kirkby Stephen, I came across a By A. E. PORTER, M.A., M.D., boy aged 13 who ten years before was stricken Medical Officer of Health, Reigate Borough and with a severe type of poliomyelitis. He was Rural District. quite crippled in both lower limbs. After in- quiry in the village and elsewhere, this strange T a period when there is an increasing story emerged :- A demand ' for the inclusion within the Forty-two years ago 3 boys, aged about 3 sphere of public health activity of non-com- years, had poliomyelitis within ten days of each municable diseases, both medical and surgical, other: one was the vicar's son, the other the an apology seems t0 be almost indicated for blacksm.ith's son, and the other a farmer's son introducing so hackneyed and threadbare a --the two latter were playfellows and were the subject as diphtheria. first to be affected ; the vicarage was invaded Nevertheless, in spite of an apparent decline about a week after this. All were paralysed. in the general mortality from this disease in In each case the paralysis persisted. The recent years, and especially since 19o2, the blacksmith's son lived in the village '.ill about country is in about the same position as it was 9 years ago. Thirteen years ago a village boy between 188o and 189o , diphtheria still account- suffered from poliomyelitis and still has one ing for between 5,ooo and 6,000 deaths annually arm paralysed, at the same time a girl aged in England and Wales. And, since the fatality 4 years had an attack. Ten years ago my school- has certainly been reduced during the last ten boy passed through his attack. Three years years or so by the use of antitoxin and the ex- ago a boy aged 4 years had an attack of polio- tension of hospital treatment, it is reasonable myelitis of the facial palsy type. All this to assume that the incidence is not falling so happened among a little community of some rapidly as might be desired, diphtheria being 2oo people. Is there a carrier case here ? of all the common infectious diseases, after perhaps smallpox, the most easily controlled Or again, why do cerebro-spinal meningitis, by direct attack. posterior basal meningitis, and poliomyelitis The well informed critic might even be dis- exist cheek by jowl in the same epidemic ? posed to suggest that, before the field of work What is the incubation period ? of the medical officer of health is enlarged in Batten suggests within 6 days. accordance with the desire of many, a more Bramwell and Currie, investigating the Tilli- determined effort should be made to deal with coultry outbreak, think 4 days. diphtheria, and, one might add in parenthesis, scarlet fever as well. Our experience in Westmorland would seem Diphtheria has been a subject of especial to point to a similar conclusion. See cases 9 interest to myself since the time that I first and IO ; II and 12; 8 and 15 ; 34 and 37. commenced practical work in our particular The late Professor William James used to branch of medicine. Whilst I was assisting say that "the field for new discoveries is always Dr. Thresh in Essex, I had charge of the the unclassified residuum." That the unclassi- hospital attached to one of his rural districts, fied residuum is a fine field for new discoveries and entered upon my duties in the middle of a in the domain of poliomyelitis, we must all big village epidemic. Nothing could be much admit. more distressinff than the arrival of child after I desire most cordially to thank the Doctors child, bearing evidence of country vigour and practising in Westmorland for the help they parental care, who nevertheless died within the so readily afforded me, and that too in the first fortnight of the disease with that almost days before poliomyelitis was made a notifiable hopeless combination of vomiting and cardiac disease. I am deeply indebted als0 to Dr. failure that is so characteristic of certain types Reginald Farrar of the Local Government of epidemics. No one who has had an ex- Board, to Dr. Craven, M.O.H. for the West- " perience of this kind, and who has personally morland combined districts, to Dr. Mathews, visited the stricken village time after time, can M.O.H. for the Kirkby Lonsdale Urban District, fail to realise the necessity for taking far more and to Drs. Batten, Edwin Bramwell, and energetic steps for controlling the disease than Mervyn Gordon for much valued counsel and * Read before the Home Counties Branch of the Society of Medical guidance during my investigations. Officers of Health, on December i6th, igri,