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A group of twelve probable cases of acute poliomyelitis
1937 A GROUP OF T W E L V E PROBABLE CASES OF A C U T E P O L I O M Y E L I T I S By E. tI. R. SMITIIARD,M.D., D.P.H., Medical Officer of Itealth, Borough of Southall. Large epidemics of acute poliomyelitis have not been recorded in England and Wales but there have been several such epidemics elsewhere. Of these may be mentioned New York in 1907 when there were 750 cases, New York in 1916 when, according to MacNalty (1986) there were 9,000 cases with %300 deaths, Quebec in 1.9:32 (Foley, 1934) when there were 1,020 cases and 130 deaths, and Denmark in 1934 (Jensen, I935) when there were 4,500 cases and apparently only some 80 deaths. In England and Wales from 19'24 to 1935 inclusive (Registrar-General, 1936), combining acute poliomyelitis with acute polioencephalitis, there were 8,648 cases notified (an average of 720 cases a year), and 1,958 deaths. The numbers for individual years ranged between 394 and 1,297, and only once was the thousand exceeded. However, in non-epidemic times it is well known that notifications are an unreliable criterion of the actual number of cases. The case fatality rate appears to vary greatly in different epidemics (from the figures given ranging from 25 per cent. in New York to under 2 per cent. in Demnark). This may be due to a greater number of abortive attacks occurring in one epidemic than in another, or to the greater recognition and inclusion of cases showing only the pre-paralytic signs. Thus in the Denmark epidemic it is stated that only 650 were cases of paralysis (this gives a case fatality rate of 12 per cent. for paralytic cases). But, apart from the case fatality, the severity of the after-results puts an urgent responsibility on the health authority for the prevention of spread of the infection. Especially is this so if there are indications that it may spread epidemically rather than occur sporadically. Unfortunately, the various means of attempted control are few, vague, and not altogether reliable. The Ministry of Health have recently issued a revised version of their memorandum on acute poliomyelitis (Memo. l(;6/Med) but this does not appear to help much in the way of control, especially at the point when it is not clear whether the disease is beginning to spread epidemically. These notes on a localised group of cases may therefore be of interest in showing up some administrative difficulties.
General R~sume The cases occurred in Southall, a London suburban town of 51,000 population, in the autumn of 1936. On October 7th a notification was received relating to a girl aged seven. This notification had been forwarded from the medical officer of health of a nearby district as the child had been diagnosed while a patient in a hospital in his district. Enquiry showed that the date of onset of the disease was September 8rd--~35 days before the notification was received. There is not necessarily any blame to be attached to a delayed notification of this sort as a case may, in the absence of other cases, be more than usually difficult to diagnose, but it illustrates one of the difficulties the health authority has to face. The next day, October 8th, a second notification, of a girl aged five, was received,
PUBLIC HEALTH having been forwarded by a metropolitan borough as the case was diagnosed in one of the London teaching hospitals. The onset of this case was September 30th. Both children were found to be in attendance at the infants' department of the same school. Although they were in different classes they mixed at playtime and probably for certain school lessons such as singing, but the 27 days between the onsets, during which there was no contact, pointed to a source of infection common to both rather than a case-to-case infection. Enquiries were made therefore with regard to recent illnesses, and absentees were followed up. Nothing suspicious was found except in the case of a girl aged five, who had been notified by the head teacher on September 7th as having been away from school since September 3rd suffering from (?) meningitis. This had been followed up in the usual way and I had been informed by the hospital (a third hospital) to which she had been sent that she was a case of " meningismus of query origin." She had made a quick recovery from her symptoms, had been kept in hospital for only six days, and had returned to school on October 5th. In view, however, of the fact that the same school was involved in these cases the matter was reported to the Ministry of Health on October 9th under the Sanita W Officers Regulations. On October 14th a further notification was received, of a girl aged six, attending a second school. The onset of her disease was October 8th. On the same day I circularised medical practitioners resident in the district asking them to let me have information regarding any case which was at all suspicious in order that if necessary it could have further investigation. As a result of this, one definite case, one probable case, and one query case of acute poliomyelitis came to light. The definite case had been admitted to a I,ondon hospital (a fourth hospital) and had died the next day, the subsequent diagnosis being ? meningitis'? poliomyelitis. The probable case had been admitted to yet another London hospital (the fifth). It was thought at one time to be poliomyelitis, then to be rheumatism, and then again to be probably poliomyelitis. The query case had been admitted to another hospital for observation (this case remained unconfirmed). A circular letter to local hospitals also brought to light another definite case, a child aged twenty-three months, and one probable case, a child aged fifteen months. Three days later, on October 17th, another child, aged six weeks, a brother to and living in the same house as one of the previous cases, was removed to hospital as a definite case. The facts that two (and probably three) cases had occurred in the infants' department of one school and that two other cases had occurred in the same house rather indicated that infection might be spreading in epidemic form. Accordingly, since sending patients to various London hospitals made administrative control more difficult, arrangements were made with the county medical officer for cubicles to be set aside at one of the county hospitals for diagnostic purposes. Medical practitioners were again circularised and the opportunity was taken, after consultation with the Ministry of Health, of recalling to them the symptoms and signs of the early stages of the disease. Three patients were admitted to hospital under this scheme in the two following days but were eventually diagnosed 227
PUBLIC HEALTH as suffering from influenza, T.B. meningitis, and constipation respectively. No further suspected cases were brought to the notice of the Health Department until November 17th, when a boy, aged eight, was admitted to hospital as a suspected case and was next day diagnosed as a definite case. He had been attending a school unconnected with any of the previous cases. An exhaustive enquiry was made at the school with regard.to absentees and contacts and these were carefully followed up. As a result it was found that another boy, aged eight, who had been a close school-contact of the previous boy, had been away from school since October 30th, and had been removed to a London hospital (the eighth) on November 9.nd. He was there thought at first to be a ? case of polioencephalitis (although this health authority was not communicated with) but was subsequently thought to be a case of cerebellar encephalitis. It seems probable that the causal virus of this and the other boy may have been one and the same. A fortnight later, on December 9nd, the last case was reported. This was a girl, aged two, who had apparently been ill for nearly four weeks before admission to hospital. There were therefore in all, twelve cases or probable cases of poliomyelitis, and five other cases at one time suspected but subsequently exonerated. P o i n t s in t h e C l i n i c a l H i s t o r i e s The following notes on the definite and probable cases, obtained from the medical officers concerned, and also from the health visitor investigating them, are included merely to give a panoramic administrative picture and not from any clinical value. They are arranged according to the date of onset, assumed retrospectively, the numbers corresponding to those in the succeeding table. 1. V. G., f., aged six. Onset 3.9.36 with chill, incontinence, general pains, general irritability. Did not improve. Admitted to hospital on 19.9.36. Afebrile on admission but had a well-marked muscular irritability and tenderness. Disease localised chiefly to the R. thigh and L. leg, the latter being worse affected. Still in hospital at the end of March, 1937, with very slight paralysis of the back muscles and the right abdominal muscles, and a greater degree of paralysis of the right thigh muscles and the left leg muscles. 3. I. S., f., aged five. Onset 3.9.36, when she was sick in school. Pains in the head. Carried to see a doctor the next day. Admitted to hospital on 5.9.36 with signs of meningeal irritation. A lumbar puncture was perfl~rmed ; the fluid was normal and not under increased pressure. Temperature I00 on admission but had fallen to normal within 48 hours. Symptoms disappeared completely within two days and no other signs developed. " It seems possible that this was a case of abortive anterior poliomyelitis which reached a stage of meningeal invasion only." Discharged on 11.9.36 and returned to school on 5.10.36. 4. F. P., m., aged four. Onset 16.9.36. Couldn't walk. Doctor called in on 17.9.36. Diagnosed as " sprained sinew " and put into plaster. Increasing loss of movement. Eventually admitted to hospital on 29.9.36. The loss of movement fairly rapidly cleared up and the child was discharged on 14.10.36 with only a suspicion of wasting of the L. thigh muscles. C.S.F. normal. Electrical responses normal. Thought to be an abortive case.
228
APRIL 7. S. W., f., aged twenty-three months. Onset 19.9.36. Five months before mother had noticed she held herself one-sided, but thought " this was just a habit " (this was eventually found to be due to congenital dislocation of the hip). Child seemed ill on the 19.9.36, T . t03. Doctor called in. Admitted to hospital on 6.10.36 " with a history of two weeks' illness commencing with a chill and high temperature. Both arms and legs said to have been paralysed the following day." On admission there was partial paralysis of the R. leg and paralysis of the L. deltoid. Some weakness of the spinal muscles. T h e dislocation of the hip has been treated and child is awaiting admission to the Royal National Orthopaedic Hospital. 8. D. T., m., aged fifteen months. Whooping cough in July. " Cold ever since." On 27.9.36 mother noticed R. leg was useless. Doctor called in on 30.9.36. Admitted to hospital on 19.10.36 with a note that he had suffered from acute anterior poliomyelitis at some date unknown. Had some wasting of the muscles of the R. leg, particularly the anterior tibial muscles, and also acute bronchitis. Discharged on 3.11.36 with condition much the same. Very little weakness and child could get about quite well. 6. M. Y., f., aged two. Onset 28.9.36. Drowsy, vomiting. Sugar found in urine on 29.9.36. Admitted to hospital on 3.10.36. No definite physical signs. T . 99. Respirations raised but not laboured. Seemed well. T h e following morning she collapsed suddenly, became very cyanosed and dyspnceic. T . 100. Recovered fairly well with eoramine but remained dyspnoeic. At 2 p.m. that afternoon she had a similar attack from which she never properly recovered and she died at 8 p.m. Postmortem showed massive collapse of both lower lobes of the lungs with a little broncho-pneumonia in the noncollapsed portions. Otherwise nothing. C.S.F. taken post-mortem showed turbidity with excess of cells, mainly lymphocytes (550 per c.mm.) and increased protein. " In view of these findings it seems probable that the lesion was an intracranial one, possibly meningitis, or perhaps an acute anterior poliomye]itls with paralysis of the diaphragm." ( N o t e : this diagnosis was made befl)re other cases of poliomyelitis in the district were known to those concerned). 2. P. E., f., aged five. Onset 30.9.36. Doctor called in that day. T h o u g h t at first to be suffering from rheumatic fever. Pyrexia, severe pains in all her limbs, headache and stiff neck. Specialist called in on 2.10.36. Paralysis was first noticed on 4.10.36 and quickly extended to the abdominal muscles and the glul}eat group. Admitted to hospital on 5.10.36. Well marked head retraction. L u m b a r puncture " showed a C.S.I~'. typical of anterior poliomyelitis." Patient left with extensive paralysis. 5. B. E., f., aged six. Onset 8.10.36. Had " a bad cold " on that day. Treated in bed for a few d a y s ; then got up and lolled about the house. Doctor was called in to see a brother on 13.10.36 and noticed that patient was ill. Admitted to hospital on 14.10.36. Disease localised to segments supplying the R. leg. Clinically a case of poliomyelitis in spite of an atypical history of onset. C.S.F. findings : 6 tymphocytes per c.mm. and normal protein. Normal in other respects. T h e neurologist is of the opinion that these results show an onset much earlier than indicated by the history. About 50 per cent. weakness at the ankle and knee, with absent tendon-jerks. After 10 days in hospital the power had almost completely returned, the ankle-jerk was present and the knee-jerk only was diminished. ( N o t e : This seems to be against " a much earlier onset " as also is the fact (unknown to the neurologist) that the next case,
1937
PUBLIC HEALTH
the brother, occurred a few days later). Discharged on 8.12.36 with considerable improvement in power of muscles affected. 9. P. E., m., aged six weeks. Onset 13.I0.36. Doctor called in because the child was suffering from wind. Sent to hospital (out-patient) for a " tube " to be passed. Got worse--screaming and crying--couldn't move R. arm and R. leg. Admitted to hospital on 17.10.36. On admission, definite paralysis of R. leg and a probable weakness of R. deltoid. General condition good. T . 100 on admission but came down to normal within 48 hours, Discharged on 21.11.36 with slight weakness in R. leg but no apparent wasting. 11. P. H., m., aged eight. Onset 31.10.36 with headache, Dizzy and could not walk, " went in opposite direction to where he wanted to go." Admitted to hospital on 2.11.36 and diagnosed as ? cerebellar encephalitis. Discharged on 28.11.36 with no paralysis and " perfectly well." Acute poliomyelitis cannot be established in this case but in view of the symptoms, and the contact with another ease, it appears possible. 12. A. F., f., aged two. Slipped in passage on 5. t 1.36. Complained of pain in L. hip afterwards. Next morning could not walk. Treated by private doctor on 9.11.36. By 1.12.36 there was no improvement; if anything the paralysis was more marked. Admitted to hospital on 2.12.36 with moderate weakness of dorsiflexors of left leg only. Discharged on 12.12.36 as her mother wished to take her out of the country. 10. V. C., m., aged eight. Onset 15.11.36 with severe headache, sickness, shaking. Put to bed. On t6.11.36 headache worse. Couldn't sit up or help himself in any way. R. arm helpless ; had to be fed. Seen by private doctor next day. ? Meningitis. Admitted to hospital that afternoon. At the end of January, 1937, it was reported from the hospital that both arms, both legs and intercostal muscles were affected. Also some bronchopneumonia. Condition poor, and for some time he had been in a Drinker's apparatus. A little better by March.
T h e following table gives the main dates in the histories of the probable poliomyelitis patients reported to the health department, and is arranged in the chro,mlogical order of the cases coming to the notice of the Department. Comments When, due to whatever cause, poliomyelitis appears to be spreading epidemically, it may be thought that strenuous public health efforts are required, but what those efforts are to be is a little vague. (Treatment does not enter into this communication b u t it may be stated that, at the time, there was no supply of convalescent serum available). Obviously isolation of the case is advisable, at any rate as far as young children are concerned. I n the group of cases in the present communication the first two at the first school (Nos. 1 and g), occurring on September 3rd, were probably infected by a healthy carrier at the school while the third (No. 2), occurring on September 30th, was probably infected either by the same carrier or another child who had been infected. Two cases (Nos. 5 and 9) occurred in the same house, the first with onset on October 8th and removal to hospital on the t4th, the second with onset on October lgth. Two other cases (Nos. 10 and 11) occurred in the same class of the same school ; there was a gap of 16 days between the last school attendance of the first and the onset of the second ; infection may therefore have been through an undiscovered third person rather than from case-to-case contact. An exhaustive enquiry failed to connect these with any earlier case. Further, the cases as a whole were fairly well spread out over the district, five in the lmrth, two in t h e middle,
I)IIOllAIHJ" CASFS OF I)OL10M YF~LITIS,
Ntllnl)er,
initials and
Final diagnosis.
age.
1. 2. 3.
V.G. P.E. I.S.
6 5 5
•1.
1:, P.
.l
5. 6. 7. 8. 9. 10. 11.
B.E. M.Y. S.W. 1). T . P.E. V.C. P. lI.
6 2
12.
A, F.
8 8
Polio. Polio. Polio. (pr-ob.) Polio. (prob.) Polio. Polio. Polio. Polio. Polio. Polio. Cerebellar enccphaliti,~ (? polio.) Polio.
Date reported to Ilealth l)epartment.
Date of onset.
7 Oct. 8 Oct. * 9 Oct.
school attendance.
1 Iospital and date of removal.
3 Sept. 30 Sept. 3 Sept.
2 Sept. 30 Sept. 3 Sept.
A B C
12 Oct.
16 Sept.
No school
D 24 Sept.
14 Oct. 15 Oct. 16 Oct. 16 Oct. 17 Oct. t7 Nov. 19 Nov.
8 Oct. 29 Sept. 19 Sept. 25 Sept. 13Oct. 15 Nov. 31 Oct.
7 Oct. No school No School No school No school 13 Nov. 30 Oct.
1~ F C C C H G
14 Oct. 30ct.~ 6 Oct. 19 Oct. 17 Oct. t 7 Nov. 2 Nov.
2 I)ec.
5Nov.
No school
H
'2 Dec.
l ,ast
19 Sept. 5 Oct. 5 Sept.
Days exposure Days exposure at school on in district whih; and after onset infectious (i.e. home and of symptoms. visitors). nil 1 I -I 10f
17 6 3 + 3+1" 9--I- 1,1
nil
nil nil
7 5 18 25 5 2 2 27
* Reported as ? meningitis on 8 Sept. t Returned to school on 5th Oct. and was possibly infectious to 15th Oct. (six weeks after onset). :I: Died on 4th Oct. 229
PUBLIC HEALTH and five in the south. The middle and south of the district are divided by a railway line with one bridge, and as far as poorer persons are concerned this tends to keep them separate. Of the three districts bordering on Southall, in one, the biggest, only one case of poliomyelitis occurred in the last five months of 19,36 ; in the second five cases occurred ; and in the third (the smallest) five definite and one suspected cases occurred. There was therefore an increased incidence in the whole of this part of the county; in spite of that the actual paths of infection could not be traced. This rather indicates that there were several abortive, unrecognised, cases in the locality. Nasal douches and gargles are advised by some authorities "for contacts although, according to other authorities, a nasal douche merely lessens the bactericidal and virucidal powers of the nasal secretions. Itowever, if contacts appeared at all apprehensive they were advised to gargle with salt and water. Disinfection of rooms, bedding, etc., after removal to hospital, is not looked on with much official favour but here again the action is a useful placebo in some cases. Probably the most effective mode of control is the close supervision of contacts. The Ministry of Health is against closing schools, and in any case even abortive attacks are usually of definite onset and the child affected stays away from school either that day or the next, thus, by its absence, calling the investigator's attention to itself. It is obviously impossible to ensure that children of a closed school-class are kept at home. When only a few children are affected, such as schoolcontacts in the same home, or particular school friends of the patient, the parent can usually be persuaded to keep the child away from other children for at any rate the first part (which is probably the most dangerous part) of the recommended three weeks. With regard to other school children all that can be done is for the health visitor immediately to visit absentees in order that if the reason for their absenteeism is in any way suspicious the parent may be persuaded tO obtain further advice. With regard to adult contacts present knowledge appears insufficient to insist on any work being given up, but had any such contacts, in this present group been engaged in, for example, the distribution of milk, an effort would have been made (based admittedly on poor grounds) to persuade them not to work or to persuade their employers to give them a few days leave. One other point of some administrative importance is the locale for treatment of the definite case and the query case. Most general hospitals appear willing (perhaps a little unfortunately) to take in cases. Because of this the first six patients in the group to come to the notice of the health authority had been diagnosed in six different London and Middlesex hospitals and altogether the 12 cases were distributed amongst eight hospitals (one hospital had four). In the absence of other cases, diagnosis of an abortive case is apt to be either missed or delayed, and even definite cases appear to be of less importance. It is probably for this reason that five weeks elapsed before the first case was notified. T h e setting aside of beds, preferably if not essentially in cubicles and at one hospital, infectious or general, is 230
APRIL advisable in order that even merely suspicious cases can be isolated at an early stage, thereby reducing the carrier and infective risk.
Summary In a mild outbreak of acute poliomyelitis tile chief administrative difficulties were : 1. Delay in the notification of the first cases. None was notified until five weeks after the onset of the first of tile series. 2. Probable missed (mild and abortive) cases. One child returned to school while possibly infectious. Modes of infection could not be traced in most cases. 3. Removal of the patients to different hospitals spread over a large area. This probably exaggerated both 1 and 2, and is of considerable importance. It is suggested that if the existence of more than a sporadic case of acute poliomyelitis appears likely local practitioners and hospitals should be circularised in order to bring to light both definite cases and possible cases; that all probable and doubtful cases should be sent to one hospital; that all school absentees should be intensively followed u p ; and that all close childcontacts should be excluded from school and observed. The series is interesting from one other point. Three out of the five cases in which lumbar puncture was performed (Nos. 8, 4 and 5) had a C.S.F. which, on the third, eighth and tenth days respectively was apparently normal. Case No. l I also had a normal C.S.F. REFERENCES.
Foley, A. R. (1934). Rep. in Bull. Ityg., 9, 737. Jensen, C. (1935). Proc. Roy. 5;oc. Med., 28, 1007. MacNalty, A. S. (t936). Brit. Med. J., 2, 59. Registrar-General. (1936,). Statistical Review : Tables, Part I. Med. As we go to press, we learn with deep regret of the death of Dr. F. Garland Collins, Medical Officer of Health of the County Borough of West IIam. An obituary notice will appear in our next issue. DR. A. E. KIDD, O.B.E., Deputy Medical Officer of ltea]th and Chief Medical Officer of the Pre-School Children's and School Medical Departments at Dundee, is about to retire after 27 years' service.
~I'HE Annual Dinner of the Medical Superintendents' Society was held at the Langham Hotel on March 20th, with the President, Dr. J. D'Ewart, who is shortly retiring from the superintendency of Booth Hall Infirmary for Children, Manchester, in the Chair. Among the speakers were Sir Cuthbert Wallace, P.R.C.S., Drs. D'Ewart, W. A. Ramsay, Ernest Ward and Adolphe Abrahams, who pointed out that, of all animals, man is the only one which speaks after dinner instead of lying down to sleep ; he further said that voluntary hospitals referred to the " threat " of State control but he preferred to call it " promise," for he was more and more impressed by the organisation, resources and wealth of material of the rate-aided hospitals.
General R~sume The cases occurred in Southall, a London suburban town of 51,000 population, in the autumn of 1936. On October 7th a notification was received relating to a girl aged seven. This notification had been forwarded from the medical officer of health of a nearby district as the child had been diagnosed while a patient in a hospital in his district. Enquiry showed that the date of onset of the disease was September 8rd--~35 days before the notification was received. There is not necessarily any blame to be attached to a delayed notification of this sort as a case may, in the absence of other cases, be more than usually difficult to diagnose, but it illustrates one of the difficulties the health authority has to face. The next day, October 8th, a second notification, of a girl aged five, was received,
PUBLIC HEALTH having been forwarded by a metropolitan borough as the case was diagnosed in one of the London teaching hospitals. The onset of this case was September 30th. Both children were found to be in attendance at the infants' department of the same school. Although they were in different classes they mixed at playtime and probably for certain school lessons such as singing, but the 27 days between the onsets, during which there was no contact, pointed to a source of infection common to both rather than a case-to-case infection. Enquiries were made therefore with regard to recent illnesses, and absentees were followed up. Nothing suspicious was found except in the case of a girl aged five, who had been notified by the head teacher on September 7th as having been away from school since September 3rd suffering from (?) meningitis. This had been followed up in the usual way and I had been informed by the hospital (a third hospital) to which she had been sent that she was a case of " meningismus of query origin." She had made a quick recovery from her symptoms, had been kept in hospital for only six days, and had returned to school on October 5th. In view, however, of the fact that the same school was involved in these cases the matter was reported to the Ministry of Health on October 9th under the Sanita W Officers Regulations. On October 14th a further notification was received, of a girl aged six, attending a second school. The onset of her disease was October 8th. On the same day I circularised medical practitioners resident in the district asking them to let me have information regarding any case which was at all suspicious in order that if necessary it could have further investigation. As a result of this, one definite case, one probable case, and one query case of acute poliomyelitis came to light. The definite case had been admitted to a I,ondon hospital (a fourth hospital) and had died the next day, the subsequent diagnosis being ? meningitis'? poliomyelitis. The probable case had been admitted to yet another London hospital (the fifth). It was thought at one time to be poliomyelitis, then to be rheumatism, and then again to be probably poliomyelitis. The query case had been admitted to another hospital for observation (this case remained unconfirmed). A circular letter to local hospitals also brought to light another definite case, a child aged twenty-three months, and one probable case, a child aged fifteen months. Three days later, on October 17th, another child, aged six weeks, a brother to and living in the same house as one of the previous cases, was removed to hospital as a definite case. The facts that two (and probably three) cases had occurred in the infants' department of one school and that two other cases had occurred in the same house rather indicated that infection might be spreading in epidemic form. Accordingly, since sending patients to various London hospitals made administrative control more difficult, arrangements were made with the county medical officer for cubicles to be set aside at one of the county hospitals for diagnostic purposes. Medical practitioners were again circularised and the opportunity was taken, after consultation with the Ministry of Health, of recalling to them the symptoms and signs of the early stages of the disease. Three patients were admitted to hospital under this scheme in the two following days but were eventually diagnosed 227
PUBLIC HEALTH as suffering from influenza, T.B. meningitis, and constipation respectively. No further suspected cases were brought to the notice of the Health Department until November 17th, when a boy, aged eight, was admitted to hospital as a suspected case and was next day diagnosed as a definite case. He had been attending a school unconnected with any of the previous cases. An exhaustive enquiry was made at the school with regard.to absentees and contacts and these were carefully followed up. As a result it was found that another boy, aged eight, who had been a close school-contact of the previous boy, had been away from school since October 30th, and had been removed to a London hospital (the eighth) on November 9.nd. He was there thought at first to be a ? case of polioencephalitis (although this health authority was not communicated with) but was subsequently thought to be a case of cerebellar encephalitis. It seems probable that the causal virus of this and the other boy may have been one and the same. A fortnight later, on December 9nd, the last case was reported. This was a girl, aged two, who had apparently been ill for nearly four weeks before admission to hospital. There were therefore in all, twelve cases or probable cases of poliomyelitis, and five other cases at one time suspected but subsequently exonerated. P o i n t s in t h e C l i n i c a l H i s t o r i e s The following notes on the definite and probable cases, obtained from the medical officers concerned, and also from the health visitor investigating them, are included merely to give a panoramic administrative picture and not from any clinical value. They are arranged according to the date of onset, assumed retrospectively, the numbers corresponding to those in the succeeding table. 1. V. G., f., aged six. Onset 3.9.36 with chill, incontinence, general pains, general irritability. Did not improve. Admitted to hospital on 19.9.36. Afebrile on admission but had a well-marked muscular irritability and tenderness. Disease localised chiefly to the R. thigh and L. leg, the latter being worse affected. Still in hospital at the end of March, 1937, with very slight paralysis of the back muscles and the right abdominal muscles, and a greater degree of paralysis of the right thigh muscles and the left leg muscles. 3. I. S., f., aged five. Onset 3.9.36, when she was sick in school. Pains in the head. Carried to see a doctor the next day. Admitted to hospital on 5.9.36 with signs of meningeal irritation. A lumbar puncture was perfl~rmed ; the fluid was normal and not under increased pressure. Temperature I00 on admission but had fallen to normal within 48 hours. Symptoms disappeared completely within two days and no other signs developed. " It seems possible that this was a case of abortive anterior poliomyelitis which reached a stage of meningeal invasion only." Discharged on 11.9.36 and returned to school on 5.10.36. 4. F. P., m., aged four. Onset 16.9.36. Couldn't walk. Doctor called in on 17.9.36. Diagnosed as " sprained sinew " and put into plaster. Increasing loss of movement. Eventually admitted to hospital on 29.9.36. The loss of movement fairly rapidly cleared up and the child was discharged on 14.10.36 with only a suspicion of wasting of the L. thigh muscles. C.S.F. normal. Electrical responses normal. Thought to be an abortive case.
228
APRIL 7. S. W., f., aged twenty-three months. Onset 19.9.36. Five months before mother had noticed she held herself one-sided, but thought " this was just a habit " (this was eventually found to be due to congenital dislocation of the hip). Child seemed ill on the 19.9.36, T . t03. Doctor called in. Admitted to hospital on 6.10.36 " with a history of two weeks' illness commencing with a chill and high temperature. Both arms and legs said to have been paralysed the following day." On admission there was partial paralysis of the R. leg and paralysis of the L. deltoid. Some weakness of the spinal muscles. T h e dislocation of the hip has been treated and child is awaiting admission to the Royal National Orthopaedic Hospital. 8. D. T., m., aged fifteen months. Whooping cough in July. " Cold ever since." On 27.9.36 mother noticed R. leg was useless. Doctor called in on 30.9.36. Admitted to hospital on 19.10.36 with a note that he had suffered from acute anterior poliomyelitis at some date unknown. Had some wasting of the muscles of the R. leg, particularly the anterior tibial muscles, and also acute bronchitis. Discharged on 3.11.36 with condition much the same. Very little weakness and child could get about quite well. 6. M. Y., f., aged two. Onset 28.9.36. Drowsy, vomiting. Sugar found in urine on 29.9.36. Admitted to hospital on 3.10.36. No definite physical signs. T . 99. Respirations raised but not laboured. Seemed well. T h e following morning she collapsed suddenly, became very cyanosed and dyspnceic. T . 100. Recovered fairly well with eoramine but remained dyspnoeic. At 2 p.m. that afternoon she had a similar attack from which she never properly recovered and she died at 8 p.m. Postmortem showed massive collapse of both lower lobes of the lungs with a little broncho-pneumonia in the noncollapsed portions. Otherwise nothing. C.S.F. taken post-mortem showed turbidity with excess of cells, mainly lymphocytes (550 per c.mm.) and increased protein. " In view of these findings it seems probable that the lesion was an intracranial one, possibly meningitis, or perhaps an acute anterior poliomye]itls with paralysis of the diaphragm." ( N o t e : this diagnosis was made befl)re other cases of poliomyelitis in the district were known to those concerned). 2. P. E., f., aged five. Onset 30.9.36. Doctor called in that day. T h o u g h t at first to be suffering from rheumatic fever. Pyrexia, severe pains in all her limbs, headache and stiff neck. Specialist called in on 2.10.36. Paralysis was first noticed on 4.10.36 and quickly extended to the abdominal muscles and the glul}eat group. Admitted to hospital on 5.10.36. Well marked head retraction. L u m b a r puncture " showed a C.S.I~'. typical of anterior poliomyelitis." Patient left with extensive paralysis. 5. B. E., f., aged six. Onset 8.10.36. Had " a bad cold " on that day. Treated in bed for a few d a y s ; then got up and lolled about the house. Doctor was called in to see a brother on 13.10.36 and noticed that patient was ill. Admitted to hospital on 14.10.36. Disease localised to segments supplying the R. leg. Clinically a case of poliomyelitis in spite of an atypical history of onset. C.S.F. findings : 6 tymphocytes per c.mm. and normal protein. Normal in other respects. T h e neurologist is of the opinion that these results show an onset much earlier than indicated by the history. About 50 per cent. weakness at the ankle and knee, with absent tendon-jerks. After 10 days in hospital the power had almost completely returned, the ankle-jerk was present and the knee-jerk only was diminished. ( N o t e : This seems to be against " a much earlier onset " as also is the fact (unknown to the neurologist) that the next case,
1937
PUBLIC HEALTH
the brother, occurred a few days later). Discharged on 8.12.36 with considerable improvement in power of muscles affected. 9. P. E., m., aged six weeks. Onset 13.I0.36. Doctor called in because the child was suffering from wind. Sent to hospital (out-patient) for a " tube " to be passed. Got worse--screaming and crying--couldn't move R. arm and R. leg. Admitted to hospital on 17.10.36. On admission, definite paralysis of R. leg and a probable weakness of R. deltoid. General condition good. T . 100 on admission but came down to normal within 48 hours, Discharged on 21.11.36 with slight weakness in R. leg but no apparent wasting. 11. P. H., m., aged eight. Onset 31.10.36 with headache, Dizzy and could not walk, " went in opposite direction to where he wanted to go." Admitted to hospital on 2.11.36 and diagnosed as ? cerebellar encephalitis. Discharged on 28.11.36 with no paralysis and " perfectly well." Acute poliomyelitis cannot be established in this case but in view of the symptoms, and the contact with another ease, it appears possible. 12. A. F., f., aged two. Slipped in passage on 5. t 1.36. Complained of pain in L. hip afterwards. Next morning could not walk. Treated by private doctor on 9.11.36. By 1.12.36 there was no improvement; if anything the paralysis was more marked. Admitted to hospital on 2.12.36 with moderate weakness of dorsiflexors of left leg only. Discharged on 12.12.36 as her mother wished to take her out of the country. 10. V. C., m., aged eight. Onset 15.11.36 with severe headache, sickness, shaking. Put to bed. On t6.11.36 headache worse. Couldn't sit up or help himself in any way. R. arm helpless ; had to be fed. Seen by private doctor next day. ? Meningitis. Admitted to hospital that afternoon. At the end of January, 1937, it was reported from the hospital that both arms, both legs and intercostal muscles were affected. Also some bronchopneumonia. Condition poor, and for some time he had been in a Drinker's apparatus. A little better by March.
T h e following table gives the main dates in the histories of the probable poliomyelitis patients reported to the health department, and is arranged in the chro,mlogical order of the cases coming to the notice of the Department. Comments When, due to whatever cause, poliomyelitis appears to be spreading epidemically, it may be thought that strenuous public health efforts are required, but what those efforts are to be is a little vague. (Treatment does not enter into this communication b u t it may be stated that, at the time, there was no supply of convalescent serum available). Obviously isolation of the case is advisable, at any rate as far as young children are concerned. I n the group of cases in the present communication the first two at the first school (Nos. 1 and g), occurring on September 3rd, were probably infected by a healthy carrier at the school while the third (No. 2), occurring on September 30th, was probably infected either by the same carrier or another child who had been infected. Two cases (Nos. 5 and 9) occurred in the same house, the first with onset on October 8th and removal to hospital on the t4th, the second with onset on October lgth. Two other cases (Nos. 10 and 11) occurred in the same class of the same school ; there was a gap of 16 days between the last school attendance of the first and the onset of the second ; infection may therefore have been through an undiscovered third person rather than from case-to-case contact. An exhaustive enquiry failed to connect these with any earlier case. Further, the cases as a whole were fairly well spread out over the district, five in the lmrth, two in t h e middle,
I)IIOllAIHJ" CASFS OF I)OL10M YF~LITIS,
Ntllnl)er,
initials and
Final diagnosis.
age.
1. 2. 3.
V.G. P.E. I.S.
6 5 5
•1.
1:, P.
.l
5. 6. 7. 8. 9. 10. 11.
B.E. M.Y. S.W. 1). T . P.E. V.C. P. lI.
6 2
12.
A, F.
8 8
Polio. Polio. Polio. (pr-ob.) Polio. (prob.) Polio. Polio. Polio. Polio. Polio. Polio. Cerebellar enccphaliti,~ (? polio.) Polio.
Date reported to Ilealth l)epartment.
Date of onset.
7 Oct. 8 Oct. * 9 Oct.
school attendance.
1 Iospital and date of removal.
3 Sept. 30 Sept. 3 Sept.
2 Sept. 30 Sept. 3 Sept.
A B C
12 Oct.
16 Sept.
No school
D 24 Sept.
14 Oct. 15 Oct. 16 Oct. 16 Oct. 17 Oct. t7 Nov. 19 Nov.
8 Oct. 29 Sept. 19 Sept. 25 Sept. 13Oct. 15 Nov. 31 Oct.
7 Oct. No school No School No school No school 13 Nov. 30 Oct.
1~ F C C C H G
14 Oct. 30ct.~ 6 Oct. 19 Oct. 17 Oct. t 7 Nov. 2 Nov.
2 I)ec.
5Nov.
No school
H
'2 Dec.
l ,ast
19 Sept. 5 Oct. 5 Sept.
Days exposure Days exposure at school on in district whih; and after onset infectious (i.e. home and of symptoms. visitors). nil 1 I -I 10f
17 6 3 + 3+1" 9--I- 1,1
nil
nil nil
7 5 18 25 5 2 2 27
* Reported as ? meningitis on 8 Sept. t Returned to school on 5th Oct. and was possibly infectious to 15th Oct. (six weeks after onset). :I: Died on 4th Oct. 229
PUBLIC HEALTH and five in the south. The middle and south of the district are divided by a railway line with one bridge, and as far as poorer persons are concerned this tends to keep them separate. Of the three districts bordering on Southall, in one, the biggest, only one case of poliomyelitis occurred in the last five months of 19,36 ; in the second five cases occurred ; and in the third (the smallest) five definite and one suspected cases occurred. There was therefore an increased incidence in the whole of this part of the county; in spite of that the actual paths of infection could not be traced. This rather indicates that there were several abortive, unrecognised, cases in the locality. Nasal douches and gargles are advised by some authorities "for contacts although, according to other authorities, a nasal douche merely lessens the bactericidal and virucidal powers of the nasal secretions. Itowever, if contacts appeared at all apprehensive they were advised to gargle with salt and water. Disinfection of rooms, bedding, etc., after removal to hospital, is not looked on with much official favour but here again the action is a useful placebo in some cases. Probably the most effective mode of control is the close supervision of contacts. The Ministry of Health is against closing schools, and in any case even abortive attacks are usually of definite onset and the child affected stays away from school either that day or the next, thus, by its absence, calling the investigator's attention to itself. It is obviously impossible to ensure that children of a closed school-class are kept at home. When only a few children are affected, such as schoolcontacts in the same home, or particular school friends of the patient, the parent can usually be persuaded to keep the child away from other children for at any rate the first part (which is probably the most dangerous part) of the recommended three weeks. With regard to other school children all that can be done is for the health visitor immediately to visit absentees in order that if the reason for their absenteeism is in any way suspicious the parent may be persuaded tO obtain further advice. With regard to adult contacts present knowledge appears insufficient to insist on any work being given up, but had any such contacts, in this present group been engaged in, for example, the distribution of milk, an effort would have been made (based admittedly on poor grounds) to persuade them not to work or to persuade their employers to give them a few days leave. One other point of some administrative importance is the locale for treatment of the definite case and the query case. Most general hospitals appear willing (perhaps a little unfortunately) to take in cases. Because of this the first six patients in the group to come to the notice of the health authority had been diagnosed in six different London and Middlesex hospitals and altogether the 12 cases were distributed amongst eight hospitals (one hospital had four). In the absence of other cases, diagnosis of an abortive case is apt to be either missed or delayed, and even definite cases appear to be of less importance. It is probably for this reason that five weeks elapsed before the first case was notified. T h e setting aside of beds, preferably if not essentially in cubicles and at one hospital, infectious or general, is 230
APRIL advisable in order that even merely suspicious cases can be isolated at an early stage, thereby reducing the carrier and infective risk.
Summary In a mild outbreak of acute poliomyelitis tile chief administrative difficulties were : 1. Delay in the notification of the first cases. None was notified until five weeks after the onset of the first of tile series. 2. Probable missed (mild and abortive) cases. One child returned to school while possibly infectious. Modes of infection could not be traced in most cases. 3. Removal of the patients to different hospitals spread over a large area. This probably exaggerated both 1 and 2, and is of considerable importance. It is suggested that if the existence of more than a sporadic case of acute poliomyelitis appears likely local practitioners and hospitals should be circularised in order to bring to light both definite cases and possible cases; that all probable and doubtful cases should be sent to one hospital; that all school absentees should be intensively followed u p ; and that all close childcontacts should be excluded from school and observed. The series is interesting from one other point. Three out of the five cases in which lumbar puncture was performed (Nos. 8, 4 and 5) had a C.S.F. which, on the third, eighth and tenth days respectively was apparently normal. Case No. l I also had a normal C.S.F. REFERENCES.
Foley, A. R. (1934). Rep. in Bull. Ityg., 9, 737. Jensen, C. (1935). Proc. Roy. 5;oc. Med., 28, 1007. MacNalty, A. S. (t936). Brit. Med. J., 2, 59. Registrar-General. (1936,). Statistical Review : Tables, Part I. Med. As we go to press, we learn with deep regret of the death of Dr. F. Garland Collins, Medical Officer of Health of the County Borough of West IIam. An obituary notice will appear in our next issue. DR. A. E. KIDD, O.B.E., Deputy Medical Officer of ltea]th and Chief Medical Officer of the Pre-School Children's and School Medical Departments at Dundee, is about to retire after 27 years' service.
~I'HE Annual Dinner of the Medical Superintendents' Society was held at the Langham Hotel on March 20th, with the President, Dr. J. D'Ewart, who is shortly retiring from the superintendency of Booth Hall Infirmary for Children, Manchester, in the Chair. Among the speakers were Sir Cuthbert Wallace, P.R.C.S., Drs. D'Ewart, W. A. Ramsay, Ernest Ward and Adolphe Abrahams, who pointed out that, of all animals, man is the only one which speaks after dinner instead of lying down to sleep ; he further said that voluntary hospitals referred to the " threat " of State control but he preferred to call it " promise," for he was more and more impressed by the organisation, resources and wealth of material of the rate-aided hospitals.