During the past summer months New York city has had an active epidemic of acute anterior poliomyelitis, and while cases of this disease have appeared from time to time, it is practically the only extensive epidemic that the great city has known, at least in the memory of the present generation of practitioners. Following, as it were, so closely the epidemic of cerebro-spinal meningitis of last year, some clinicians have endeavored to show some relationship between these two diseases, but as yet nothing definite has been proven.

The first reported epidemic of poliomyelitis occurred in Louisiana in 1841. During the year 1894 there occurred a small epidemic in the Otter Creek Valley, Vermont. From June to August of that same year 150-odd cases were reported. At the same time a peculiar disease appeared among the domestic fowls, which, according to the pathologist, showed a degeneration of the cells in the anterior horn of the spinal cord of chickens, etc. From time to time similar epidemics have occurred in Norway and Sweden.

ETIOLOGY.

The cause of this disease is veiled in mystery. Since the time Duchenne first described it little has been added. It is generally stated that age, season and infectious diseases are the three most important factors. During the months of July and August, 1905, 1906, 1907, the following cases of scarlatina, measles

and pertussis were reported to the New York City Department of Health:

1905. 1906. 1907. 1905. 1906. 1907. -July.

-August205 197 484 662 317 799

Scarlatina.. 256 333 1078
Measles. 1686 1155 1991
Pertussis... 247 207 144 197 196 123

It will be noted from the table that during the last two years there is an increase in the number of cases of scarlatina and measles. This may be explained by the factor that the physician is more particular in reporting cases. It is interesting to note that in the present epidemic all or most of the children were perfectly well before the attack. and there was no association whatever with other acute infectious diseases. Up to 1897 Dana collected 50 cases, of which 39 were children-males 24, females 15.

Terriberry of New York, who first called attention to the recent epidemic, and from a study of a similar epidemic at Ridgeway, Pa., thinks that these cases have their origin in low-lying districts and that they occurred at a time when the

rainfall was much reduced-i. e., in the summer months during the dry season. He also traced the disease along the course of a dirty stream.

The fact that most of these cases occurred during the hot summer months has suggested that the cause of this disease is probably through the intestinal tract, although accurate data concerning this view is still wanting. According to Dr. Simon Flexner there was no evidence of any inflammatory condition as far as the spinal fluid was concerned, and all cultures taken gave a negative result.

The exact number of cases that have occurred here in the city may never be known, but it is certain that they reached into the thousands. According to Dr. V. P. Gibney, 387 cases were seen at the Ruptured and Crippled Hospital alone, this number being nearly ten times the number of cases seen during the previous year.

Dr. L. Emmet Holt says that it looked very much as if the disease was an infectious one, as was indicated by more than one case occurring in the same family. It affected all classes of people, even adults.

SYMPTOMATOLOGY.

Many cases gave a typical history—i. e., high fever, rigid neck, vomiting, a convulsion, followed in a few hours or days by paralysis while many more cases developed unusual symptoms. Dr. L. E. Holt reported a case before the Section of Pædiatrics in which all four extremities, together with the muscles of respiration, except the diaphragm, were

paralyzed. Pain in the extremities was

marked feature, and the question whether one was dealing with a peripheral neuritis or poliomyelitis was often a difficult one to answer. Some cases in early stage were diagnosed cerebrospinal meningitis in which several days later paralysis appeared. Some cases were comatose, and Dr. C. G. Kerley has reported such a case that was in that condition for four days. Several cases of this disease had the paralysis limited to the facial nerve. Blood cultures taken in this disease showed negative results. The blood count showed a slight leucocytosis. The stage of invasion may be so sudden as to suggest hæmorrhage. Clopatt of Germany reports a case of anterior poliomyelitis in which ocular pupillary symptoms were present, together with a ptosis of the lip.

The writer has collected a series of six cases of acute anterior poliomyelitis seen during the last summer at his clinic at St. Mary's Free Hospital for Children, and takes this opportunity to report them.

Case I. A typical history was obtained. The patient was a boy, eight years old, who had always been healthy. On the afternoon of August 29, 1907, the child came to the house from play and complained of being tired. That same night, about 2 A. M., the mother said that the child had an "awful fever," together with a stiff neck. She gave him a hot mustard bath, after which the child went to sleep. The next morning the child appeared to be much better, but remained in bed during the day. There were no gastro-intestinal disturbances. The writer saw the patient September 6, just one week after the onset, when the patient complained of pain in the left hip and leg, together with loss of function of the entire lower left extremity. Rheuma

tism was excluded. The skin was cold and had a reddish mottled look. The muscles were flabby and the patella reflex was absent. The boy had as well an enlarged thyroid gland. The boy's left leg was immobolized in plaster of paris, the leg being extended upon the thigh and the plaster was carried well up toward the hip. This was left on for two weeks, after which it was removed and massage treatment was begun.

Case II. Charles S., 14 months old. The mother said that the child had been restless and crying for some few days before the attack. On August 19, 1907, the child had a convulsion, which was followed by a "fever," which lasted 48 hours. No diarrhoea or other gastrointestinal trouble was present. On August 27, 1907, the mother noticed that the child's left arm was limp. Birth paralysis was excluded. October II, 1907, a marked paralysis of the left deltoid muscle was very apparent. This case was taken sick while living on a canal-boat. Case I and Case II were cousins.

Case III. John F., colored, four years old, was taken sick August 5, 1907, with a "high fever." The family doctor was called and said that the child had a temperature of 103° F. The next day the Ichild was better. Two weeks later the father noticed that the boy could not use his legs and there was some loss of function of the left arm. The writer first saw this case on October 16, 1907. The following facts were brought out by physical examination: The child was large for his age, well nourished and bright. Both legs had been paralyzed, but some improvement had taken place in the right leg; function of movement had been fairly recovered.

Both patella reflexes were absent. The left leg showed no improvement in re

gaining the function of the anterior tibial group of muscles. The deltoid muscle of the left arm was paralyzed, but the child makes use of pectoral muscles, and in this way was able to partly raise the arm.

Case IV. Thomas R., two and onehalf years old, of Tottenville, Staten Island, N. Y. .The child was taken sick on August 27, 1907, with a "high fever," which lasted 48 hours. One week before this the boy had an attack of diarrhoea. During the fever a marked stiffness and rigidity of the neck was present. On the fourth day the mother noticed that there was something wrong with the boy's feet and legs, and, as she expressed it (being an ignorant woman), the child "turned yellow around the toes" (change in circulation), and then she noticed that a paralysis of both legs was present. On October 30, 1907, the boy was examined at the clinic and the following facts were obtained: Both legs were involved and apparently both had been completely paralyzed, but some slight improvement had recently taken place. The patella reflex on the left side was present, but slightly diminished from the normal. The patella reflex on the right side was entirely absent, together with a complete "foot-drop." The toes of both feet were movable. The skin of the right leg was cold and presented the characteristic mottled appearance.

Case V. Harry H., 14 months old, was taken sick September 20, 1907, in the middle of the night with "high fever." The family doctor at first thought the case one of meningitis, but within 48 hours paralysis of both legs appeared.

Case VI. James T., five months old; second child. Mother had normal labor; child fed partly on breast, partly on condensed milk. When six weeks old the child was taken sick and had "high fever," which lasted about 10 days.

When first seen several weeks later the child had left-foot drop, with inversion of foot, plus adduction of same leg; left forearm contracted on arm; right foot clubbed internally (muscular); liver was enlarged. Child was well nourished and fat.

TREATMENT.

In regard to treatment in this disease there was an apparent feeling among general practitioners that the orthopædist was the only one who could do any good.

This was a mistaken idea. Much can be done for these cases before deformities develop.

In the acute stage the child should be put to bed and kept there. Rest is the most important thing. During the past epidemic some cases were cured by rest alone. Dr. A. B. Judson of New York says "as soon as this disease is recognized he would limit the patient to the recumbent position till there is no possibility of further reaction of the paralysis." Some have suggested continuous hot or warm bath during the spasm. Ice bags along the spine were of value. When the temperature was low and pain was marked the application of mustard. paste along the spine was beneficial. The affected extremity should be kept quiet and warm for at least two weeks. attention should be directed toward the gastro-intestinal tract, and calomel is of great value. Later on the environment

The

and general hygiene of the patient should not be overlooked. After four weeks electricity is of benefit. Massage tones the muscles and tends to overcome their rigidity. Passive motion and exercises are of great value. Plaster of paris casts overcome muscular contractions and thus prevent deformities. After several months orthopaedic apparatus or tendon transplantation may be necessary. Welladvised medicinal and dietetic treatment are of utmost importance and should be continued, together with the local treat

ment.

The Section of Neurology and the Section of Pædiatrics of the New York Academy of Medicine have appointed special committees to study the etiology of this disease. This is a step in the right direction, and much good to the profession as well as the patient will be derived from their investigation, but it will probably be at least one year before their report can be completed. It has been estimated that nearly one-half of the lameness seen on the public highway is caused by infantile paralysis; consequently anything that can be found to be of value along hygienic lines or preventive medicine that will stamp out this terrible disease will be most heartily welcomed by the medical profession. The effects of acute anterior poliomyelitis are perhaps the most pathetic in the whole practice of medicine-little children crippled for life at a time when life has just begun.

The Death of Prof. von Esmarch.On February 24, 1908, Prof. Dr. Johannes Frederick August von Esmarch, one of the oldest of German surgeons, died at Berlin at the mature age of 85 years. He was best known for the bloodless method of performing surgical operations. He

was founder of the German Samaratieran Corps in 1872. Esmarch married Princess Henrietta von Schleswig-Holstein Sonderberg-Augustenberg, an aunt of the present Emperor of Germany.

Prof. von Esmarch was born at Tönning, in Schleswig, on January 9, 1823.