tion conforms to the Galenic principle-contraria contraribus curentur, (let opposites be treated by their opposites).

(Homœopathic therapeutics and vaccine therapy of whooping-cough will be taken up in a subsequent article.)

535 Beacon Street.

1 Baginsky, A.

Pertussis, in Infectious Diseases, edited by Wilson, J. C. and Salinger, J. L. New York, 1908, p. 784.

2 Ruhråh, J.-Whooping cough, in Modern Medicine, edited by Osler and McCrae, New York, 1913, I., 661.

Ruhräh, J. —Whooping-cough, in Forchheimer's Therapeusis of Internal Diseases. II., 174.

Mallory, F. B. and Horner, A. A. Jour. Med. Research. 1912, xxvii, 115. 'Ladd, M.- Vaccines in the treatment of pertussis. Arch. Pediatrics, 1912, xxix, 581. Kolmer, J. A. -The diagnostic value of a blood examination in pertussis. Am. Jour. Dis. Children, June, 1911, p. 439.

7 Walcott, W. W.

Field Work of the State Dept. of Health on Communicable Diseases, Bos. Med and Surg. Jour., 1916, clxxiv, 341.

Ruhräh, J. loc. cit., 659.

Friedlander, A. and Wagner, E. A. Diagnosis of whooping-cough by the complementdeviation test. Am. Jour. Dis. Children, Aug. 1914, p. 136.

10 Willis, Thomas. (1622-1675) "de Medicamentorum Operationibus." Sect. I. Cap. vl., quoted by Robert Watt in Treatise on Chincough, Glasgow, 1813, p. 22.

11 Sydenham. - Swan's translation, p. 231.

22Cullen, William - First lines of the practice of physic. §1419.

13 Loc. cit., p. 213.

ACUTE POLIOMYELITIS*

BY SAMUEL A. CLEMENT, M.D., Boston, Mass.

Poliomyelitis is an acute infectious, and supposedly contagious, disease of the central nervous system, occurring both in epidemic and sporadic forms, characterized by sudden onset, fever, vomiting, headache, lameness, hyperæsthesia and catarrhal irritation, commonly and promptly followed by a flaccid paralysis corresponding to the amount of damage to the gray matter of the cord or brain, and in time leading to a progressive regeneration, although it may leave permanent atrophy of the muscles, and deformities.

HISTORY

The old name "Acute Anterior Poliomyelitis," commonly known as "Infantile Paralysis," is really a misnomer. We now know that the gray matter in the anterior horns is chiefly affected, but the gray matter in the posterior horns, the motor nuclei of the cranial nerves, and cells in the cerebral cortex are also involved. As to "infantile," cases have been reported from birth to 74 years of age. We do not as yet know a suitable name for this disease.

Read before the Massachusetts Homœopathic Medical Society, November 1, 1916

Poliomyelitis is a disease which has not attracted much notice in the sporadic form which occurs chiefly during the cold season, but has attained a high rank and wide interest in its epidemic form, occurring usually during warm weather and cropping out, possibly after skipping a few years, in places of its original occurrence.

In 1840, Heine separated this paralysis from other forms of paralysis. Colmer, an American physician, in 1841 recognized the first real epidemic. In 1884, before the International Congress, Medin described the clinical types of poliomyelitis much to the astonishment of prominent pediatrists who still retain the old name, acute anterior poliomyelitis. Medin called attention. to a widespread epidemic in 1887 which occurred in Sweden and Norway, especially studied by Wickham. In 1894 Caverly described an epidemic in Vermont. In all, including 1916, fortythree epidemics have been observed in America and on the Continent. The epidemic of 1907-08 in New York City reached 2,000 cases. The present epidemic is the largest the world has ever known. Approximately 20,000 cases have been reported.

ÆTIOLOGY

Predisposing Causes. The majority of cases occur between 6 months and 10 years of age, although many cases are seen in young adults and even to 74 years. Low resistance, previous diseases, overwork, loss of sleep (especially in adults), exposure, unsanitary surroundings, lack of sunshine, may favor the disease, but every case must originate from another case.

Many times one would be led to think that poliomyelitis has a predilection for healthy, robust individuals. It has no respect for the most hygienic surroundings, nor for wealth, although the majority of cases are among the poorer classes. It seems to select one individual out of a large family. Two and even five cases have been reported in the same family, but it is rather unusual. When two or more cases are found in the same family, they seem to have contracted the disease at the same time.

The disease is probably due to a minute filterable microorganism which has been found in the secretions, excretions, and tissues of patients, attendants, other members of the family, etc. This bacterium has been cultivated, inoculated into monkeys and the disease produced in them.

PROBABLE METHOD OF TRANSMISSION

Since the virus is found in the mucous secretions from the beginning of the disease to even 6 months afterwards, it is

logically assumed that it is transmitted by direct or indirect contact, as are measles, diphtheria, whooping cough, etc.

Facts against its being transferred by direct contact

1. Extreme rarity of the disease in doctors, nurses, and other attendants.

2. Entire absence of the infection in laboratory workers who have experimented with the virus.

3. Comparatively rare occurrence of two cases in the same family.

4. Failure to spread in schools, hospitals, and institutions where one case had been found.

5. Comparatively maximum prevalence of the disease in country districts where personal contact is least intimate.

6. Summer incidence of the disease. The vast majority of cases occur during the warm weather when people are more in open air. With the onset of winter, when the population becomes more and more congested in houses, schools, etc., its morbidity is markedly reduced while the other so-called communicable diseases are much increased.

Facts as to transmission by insects

1. We know that malaria and yellow feyer are transmitted by mosquitoes. Poliomyelitis being more prevalent also during the warm season, and since we do not know definitely its method of transmission, it would lead one to think that it might be transmitted by flies or other insects.

2. The disease also being more prevalent near lakes, rivers, low marshy lands, dumps, where flies and mosquitoes are most abundant, would favor the insect theory.

3. The fact that the disease occurs in well-to-do people on high lands, in most hygienic surroundings, militates against this theory, as does the existence of winter epidemics, such as was reported in Sweden (from November to the middle of March).

INCUBATION PERIOD

It varies from 2 days to 2 weeks with an average of 10 days.

SYMPTOMATOLOGY

1. Prodromal or pre-paralytic stage. The constitutional symptoms may be very severe or unnoticed. Sudden onset, fever, vomiting, headache, irritability, general hyperæsthesia, lameness, backache, stiffness of neck muscles, profuse sweating,

and drowsiness are the most important symptoms. If there can be obtained a history of exposure to the disease, it is advisable to isolate the case. Examination of the spinal fluid will usually help in the diagnosis. During this period retention of urine has been observed in several cases. The sphincter seems to be normal but the wall of the bladder has no expulsive power. The same condition has been noticed in the lower bowel. When a case presents these prodromal symptoms with temporary weakness in the muscles but no paralysis, the diagnosis of abortive poliomyelitis is usually made, especially if there should be another case with definite paralysis near by or in the same family.

2. Paralytic stage. Following the above symptoms, usually on the fourth or fifth day, paralysis is noticed. The amount of paralysis does not necessarily depend on the severity of the onset and of course corresponds to the amount of damage to the central nervous system. Since any part of the motor tract in the brain and cord may be involved there are no muscles exempt from paralysis. Just as the paralysis makes its appearance, the acute febrile symptoms gradually subside and the paralysis rarely increases after the temperature has been normal for 48 hours. A few cases at the West Department have shown a sort of relapse (reinfection?); two died at the end of 10 days from respiratory involvement.

Reflexes. As this is a flaccid paralysis, the reflexes are absent in the affected muscles. The knee jerk is lost in quadriceps paralysis, while the plantar will be normal unless the muscles of the foot are affected. In the bulbo-pontine and meningeal types of poliomyelitis the reflexes are exaggerated. Rarely, a Babinski, active knee jerk and ankle clonus are observed in this paralysis, showing that the extensors of the knee and the extensors and flexors of the ankle have escaped paralysis.

Diagnosis. The diagnosis is based upon the following points: History of exposure, age, presence of an epidemic, a suggestive incubation period, fever, vomiting, headache, malaise, irritability, rigidity, hyperæsthesia, shooting pains in the extremities, altered reflexes, drowsiness, and weakness in the limbs. With these symptoms, if the cells in the spinal fluid are increased in number and are chiefly lymphocytes, and if there is increased globulin, the most probable diagnosis is poliomyelitis.

3. Stage of repair. This is the most interesting stage to study. At the very onset of the paralysis the central nervous system in many cases seems to be overwhelmed with poisons, and on examination the patient is found to be in a stupor, unable to move a toe or finger, so that the first examination is very discouraging. Soon, however, the toxic effects disappear,

the patient is brighter, and gradually the limbs become more freely movable, indicating that those regions of the central nervous system which were only poisoned or compressed are restored to their normal functions. The muscles which remain paralyzed show the real extent of destruction to the gray matter in the cord and brain. The reflexes which may have been lost are likely to reappear in a few days.

OBSERVATIONS ON POLIOMYELITIS AT THE WEST DEPARTMENT FROM AUGUST 12 TO NOVEMBER 1, 1916

During this epidemic a peculiar maculo-papular eruption has been noticed in several cases during the onset of the disease. The first case of poliomyelitis was admitted to the hospital as measles or scarlet fever because of this unusual rash. We have admitted 130 cases. The vast majority were brought into the hospital on the fourth or fifth day of the disease, because, as I have said before, the paralysis is usually noticed at that time and the diagnosis is commonly not made before the paralysis appears. So we have found the temperature nearly normal; and extension in the paralysis while in the hospital has rarely been observed.

A few cases, showing paralysis of one limb with a fairly high temperature (102-103) on admission, on the next day presented more paralysis. The three most remarkable instances. of spread in the paralysis after admission were the following:

1. A girl of 8 years came in with paralysis of the upper left extremity, and remained so for five days. On the sixth day she developed respiratory paralysis and died within twenty-four hours.

2. A man of 30 years who was clinically diagnosed poliomyelitis, with paralysis in both lower extremities. This patient did well for a week and on the tenth day the thoracic muscles became involved and he died in a few hours, showing exactly the same symptoms as several undoubted cases dying of respiratory failure, the heart beating for several seconds after the last respiration. This case was interesting, since the pathologist could not find any lesion in the central nervous system at post mortem and no other cause of death was found.

3. A boy with paralysis of both legs on admission developed paralysis of the ocular muscles after five weeks.

As a rule, if the patient survives the first five days, he will recover. All but two of the cases that died were moribund on admission and died within 24 hours.

Twelve cases were of the ascending type (Landry's paralysis), and died in a short time from respiratory failure.

Four cases had only a left facial paralysis.