TEXT |
HARpub Commentary |
Note. -- The details
of this investigation will appear later in a
publication of the Massachusetts State Board of
Health. |
|
The following investigation of this epidemic here
published in abstract was made at the sugggestion of
Dr. Henry P. Walcott, chairman of the State Board of
Health. The information was obtained through the
courtesy and assistance of the physicians which
enabled the writer to visit the homes of all the
cases reported in this epidemic. The writer spent a
month living in the towns in which the epidemic
occurred and made several subsequent visits to these
places. |
|
Geographical Distribution |
|
Sixty-nine cases of infantile paralysis, or
approximately one half the total number reported in
the state during 1908, occurred in western
Massachusetts and were distributed as follows: |
|
Colrain |
24 |
|
Erving |
2 |
Buckland |
9 |
|
Adams |
1 |
Shelburne Falls |
8 |
|
Cheshire |
1 |
Montague |
7 |
|
Deerfield |
1 |
Bernardston |
5 |
|
Gill |
1 |
Greenfield |
4 |
|
North Adams |
1 |
Heath |
4 |
|
West Hawley |
1 |
|
[Map Of
Franklin County, tasked] |
With the exception of three isolated cases in
Adams, North Adams and Cheshire, the cases occurred
in a sparcely-settled portion of the state in the
larger towns (Shelburne Falls, Buckland) on the
Deerfield River, and its main feeder, the North River
(Colrain), and at that point on the Connecticut
(Turners Falls) where the Millers and Falls rivers
empty into it. As both the valleys of the Deerfield
and North rivers are very narrow, the bulk of the
population lives naturally very near these streams. |
|
Twenty-four cases occurred in Colrain (population
1,800), a town of five villages containing three
cotton mills in the narrow North River valley. Nine
of these cases occurred in Griswoldvile (population
350), the largest of the three mill villages.
Thirteen cases occurred in the village af Shelburne
Falls, a manufacturing town with a population of
2,500, which includes the villages of Shelburne Falls
and Buckland which are separated by the Deerfield
River only. Six cases occurred in Turners Falls, a
large manufacturing town on the Connecticut River,
and two cases were other towns across the river. |
|
Fifty-two of the 66 cases were located in the
valley on these streams, while 10 of the remainder
were hill cases in country districts adjacent to
these towns. There were 3 scattered cases in
Greenfield. The actual distance from the houses where
the cases occurred to these streams above mentioned,
including mill ponds, canals, etc., was found to be
as follows: Four cases were one quarter of a mile
distant, 15 cases were one eighth of a mile distant,
33 cases were less than 500 ft. distant, of which 20
cases were from 10 to 200 ft. distant. |
Most
cases were in valleys near the streams. |
The relation of the hill cases to those in the
valley was noted, and in every case it was found that
the hill cases gave a history of visiting, driving or
in some way spending time in the nearby towns which
were upon the streams as above mentioned. It may be
stated that there was no case in the 66 under
consideration which had not been exposed recently to
the valley influences, if any. |
Every
hill case visited areas near waterways. |
In addition to the above 69 cases in western
Massachusetts, 6 cases of infantile paralysis
occurred in southern Vermont in territory, contiguous
to the Colrain-Heath district. They all appeared to
be independent cases and 4 of them were located near
the Deerfleld River or its branches. |
[A
map of the upriver area in Vermont, and nearby
industry, is tasked.] |
Sequence
Of Cases |
|
Sixty-five of the cases occurred in the summer
months as follows: June, 6; July, 28; August, 26;
September, 5; while isolated cases occurred in March
1, April 1 and in November 2. The height of the
outbreak appears to have been July 25 on which date 6
cases occurred in four towns as follows: Bernardston
2 (one family), Buckland 2, Shelburne Falls 1,
Colrain 1. The early cases occurred at various points
throughout the district concerned as follows: In
Turners Falls district June 4 (the earliest case), in
the Shelburne Falls district June 20, in the Colrain
district July 1 in the southern part of this
territory, and July 4 in the northerly part of this
section. The outbreak in the various towns, with the
exception of a few small groups, was not an explosive
one, but cases occurred from time to time, covering a
period of from six to eight weeks in each town. |
|
Contact And Relation Of Cases To
Each Other |
|
Turners Falls Village and suburbs. --
The first case occurred in Turners Falls village on
June 4, and from this time on to July 20 there were 7
additional cases in this district. There was 1 case
of known contact and 2 of possible contact. |
|
Greenfield-Deerfield.-- Four independent
cases occurred in these towns from July 9 to Sept. 8. |
|
Bernardston. -- There were 3 cases
practically coincident in one family July 25 and 2
cases in another family, the second being sick three
weeks after the first. |
|
Shelburne Falls. -- The first case in
this group occurred June 20 on a mountain farm and
the second case developed in this family one week
later. There were 6 other cases in this group during
July and August, 2 being coincident in one family,
and 1 contact - case having frequently visited one of
the cases. |
|
Buckland. -- There were 2 cases
practically coincident in one family and one contact
case who had visited, a neighbor’s sick child.
There were 5 additional cases in this town during
July and August. |
|
Colrain. -- Three cases occurred in the
village of Frankton and had their first symptoms July
7, 16 and 25. The houses were 75 ft. apart and there
was more or less commingling of all the children. Six
cases occurred in the village of Shattuckville, 2 of
which were coincident in one family on July 16 and
17, and 2 were coincident in another family on Aug.
3. There were 9 cases in the village of Griswoldville
during July and August, 8 of which were independent
and 1 a contact case who had been sleeping and taking
care of her younger sister. At Willis Place there
were 3 independent cases in a large tenement block. |
HARpub
postulates Colrain as the main upstream source of
polio-producing pollutants. Here were the greatest
density, the greatest number of victims, and 3 cotton
mills poised on the edge of the river which flows
down through the other areas with lesser densities of
cases. Carbon tetrachloride, used in cottonseed oil
extraction at this time had just gone into
unprecedented high volume production in the U.S. (not
mentioned in the article). |
The 54 cases just reviewed constitute what may be
called the group cases, of which 43 are independent
and 11 are possible contact cases, 7 of which are of
known and 4 of possible contact. The 15 remaining
cases are all independent, 9 of which are connected
by location with the groups above mentioned and 6 are
isolated. |
|
Independent Cases |
|
Group |
43 |
|
|
Connected With The Group |
9 |
|
|
Isolated |
6 |
|
|
SubTotal |
|
58 |
Contact Cases |
|
Known |
7 |
|
|
Possible |
4 |
|
|
SubTotal |
|
11 |
|
|
|
|
|
Total |
|
69 |
|
|
Time
Interval |
|
The time interval elapsing between the exposure
and onset of symptoms of the 7 cases of known contact
is as follows: Three cases of intimate contact with
intervals of 24 days, 14 days and 8 days; 4 cases of
contact not intimate, 14 days, 9 days (two instances)
and 7 days. |
|
Out of the whole number of cases there were but 2
that were isolated during their illness. One was in a
family in which there were no other children and 1
was in a house in which there were 3 children, and
this case was as thoroughly isolated as if it were a
case of scarlet fever. The remaining 67 cases were
not isolated in any degree except that in a few
instances the serious illness of the child was a
sufficient bar to any intimate contact with the other
children in the family. |
|
Careful inquiry into the conditions that obtained
during the illness of the 67 in which there was no
isolation shows that there were 166 children in these
families, 4 of which later had the disease; that
there were 4 instances in which the sick child slept
with a brother or sister up to the time of illness, 7
during the first few days of illness and 5 throughout
the entire illness; that there were 9 instances in
which the other children of the family drank from the
same cup; that there were 12 instances in which the
children in the family and neighbors children kissed
the sick child during the acute illness. It is
impossible to determine the number of times that
contact of the kind just mentioned occurred, but the
above detail indicates to how great an extent the
intimacy of the well with the sick did occur. Out of
the entire number involved to the intimate contact
just described, 2 cases developed the disease. |
|
Investigation further showed that there were, in
addition to the 166 exposed children in the families,
86 children among neighbors and friends (making a
total of 244 children) who were in intimate contact
with the 67 cases. By intimate contact is meant (and
this appeared to be almost universal) as free
intercourse of the well and the sick as the
patient’s condition would permit. Playing with
the child, sitting beside him, taking naps lying on
the lounge or bed with him were the conditions that
existed in almost every case. The total number of
children that were more or less intimately exposed to
the 67 cases is probably at least twice or three
times the number of known exposures. |
|
Weather |
|
A study of the plotted curves of temperature,
rainfall (secured from the report of the Hatch
Experiment Station at Amherst) and incidence of cases
appears to show no correlation whatever. |
|
Diet |
|
Investigation of the diet showed the following:
General diet 58, cow’s milk exclusively 4,
breast milk and cow’s milk 3, breast milk and
fruit, etc., 4. Milk was found to be used in
considerable quantities by 29 cases, in small amounts
by 26, while 3 cases used no milk at all. Nineteen
families produced their own milk and there were 22
milkmen serving 36 families, while the milk for the
remainder of the cases was bought from various
sources. None of the infants under one year of age
were fed upon breast milk alone. |
|
Diet Of
Victims (HARpub) |
General
diet |
58 |
Cow's
milk, exclusively |
4 |
Breast
milk, and cow's milk |
3 |
Breast
milk, and fruit, etc. |
4 |
Milk,
considerable quantities |
29 |
Milk,
small amounts |
26 |
No milk |
3 |
|
|
Milk,
family produced |
19 |
Milkmen, serving 36
families |
22 |
Breast milk fed
infants <1 Year |
0 |
|
62
of the 69 cases were drinking cow's milk. Yet, no
breastfed infant under 1 year acquired infantile
paralysis. Breastmilk would have less pesticide than
polluted cows's milk, water, or produce. Cow's milk
and water are prime suspects for HARpub, in terms of
toxicology. Cows could go to the streams and guzzle
large quantities of polluted water, concentrating
organochlorines in milk fat. |
Unusual Diet |
|
It was not found possible to get a more detailed
history of the diet than is given above, except that
in 6 cases it was especially mentioned that fruit and
berries had been a very large item of diet. In the 2
infants, five and eight months old, bananas and
berries were given as the diet in addition to breast
milk. In 1 case the illness was attributed to eating
heartily of English mulberries and in 3 cases to the
eating of large amounts of blackberries and
blueberries. In 39 instances it. was stated that food
supplies were bought from peddlers, and it was found
that these carts frequently served the town and
country districts in their localities. |
|
Preceding
Illness |
|
Practically all the cases had been in good health
previous to this attack. One child was in very feeble
health, 5 were in a more or less run-down condition
and 63 were in their usual condition or good health.
(One had recovered two months before from a slight
attack of scarlet fever.) |
|
Condition Immediately Preceding
Onset |
|
Traumatism. -- There
were 3 cases of traumatism as follows: |
|
Fall from bicycle three weeks before
illness. |
|
Fall from piazza four weeks before
illness. |
|
Burn of arm and chest three weeks before
illness. |
|
There were no special symptoms subsequent
to the two falls, and the burn was healing
properly when infantile paralysis developed. |
|
|
Over-heating. -- Five cases gave a
history of possible over-heating within a day or two
of the onset of the disease. |
|
Fatigue. -- Four cases were noted as
suffering from marked fatigue within a day or two of
this illness. One was a child of seven who had been
carrying bricks up a ladder the day before he was
taken ill, another was a young man of eighteen who
was a noted athlete, a third had been lifting very
heavy weights and a fourth was tired out with school
work. |
|
Swimming. -- Five cases had been in
swimming in the streams nearby and 6 cases, among
children, had been playing in the brooks, ponds, etc.
|
|
One child had a severe cold just before the
symptoms of this disease appeared. It was noted in 1
case in a young man nineteen years old that he had
been extremely nervous and very much worried for fear
he would develop this disease, as he had recently
attended a funeral of a classmate who died from
infantile paralysis. |
|
Abortive
Cases1 |
|
There were 6 cases reported which, on
investigation, were found to have the same acute
symptoms as the other cases, but to a less degree,
and no paralysis occurred. The history of these cases
seemed to eliminate the possibility of their being
simple gastro-intestinal disturbances; and while the
diagnosis of infantile paralysis cannot be proven,
the history of the cases seemed to warrant their
being considered as abortive cases of this disease.
One case occurred in a family more than three weeks
after the onset of a rather severe case in another
brother. One case was coincident (doubtful history)
with that of an older brother, while 4 cases occurred
without known exposure. |
|
Symptoms
Accompanying Attack |
|
Pain, more or less marked, 62 cases; pain, little
or none, 7 cases; fever, 63 cases; constipation, 47
cases; diarrhea, 2 cases; nausea and vomiting, 43
cases; retraction of head, 35 cases; retention of
urine, 23 cases; incontinence of urine, 1 case; brain
symptoms, 13 cases; stiffness of neck, 6 cases;
stiffness of spine, 7 cases. |
|
The onset in 65 cases was sudden and in 4 cases
it was delayed, extending over several days. |
|
Complicating Symptoms |
|
In one case a marked urticaria was an initial
symptom; in 2 cases intense pain in the stomach was
noted, also as an initial symptom; in 5 cases a
complicating tonsillitis was present; in 1 case a
severe nose bleed took place; an extremely offensive
breath was noted once; double vision occurred once,
as did also marked disturbance of speech. The early
symptoms in 1 case were thought to be due to swollen
glands, which had been present for a year, and in
another case to a rheumatic condition. In 2 cases
stumbling of the child while walking and playing was
one of the first symptoms noted. |
|
Diagnosis
Made |
|
In 1 case no diagnosis whatever was made; in 2
cases a diagnosis of typhoid fever was made and the
following diagnoses of single cases: Digestive
disturbance, heat stroke, cerebrospinal meningitis,
rheumatism. |
"We
stand between Scylla and Charybdis. In the presence
of an epidemic we are likely to call everything that
bears the slightest resemblance to poliomyelitis a
proved or almost proved case; and in the absence of
an epidemic we are almost certain to fail to
recognize cases which are perfectly definite examples
of the disease." (Dr.
Janeway, replying to Haven Emerson. From "The
Recent Epidemic of Infantile Paralysis", which
Emerson read before a meeting of The Johns Hopkins
Medical Society, November 6, 1916) Today we know that
no symptom (silent polio), the common cold, flu,
fever, gastro-enteritis, meningitis, encephalitis all
can be regarded as different stages of poliomyelitis,
which at any stage can be regarded as abortive, if it
does not continue to the more acute stage. |
Recovery |
|
Excluding the 6 abortive cases, 58 cases were
examined in this regard about nine months after the
illness. Six cases appeared to have completely
recovered from the paralysis. Six others appeared to
have recovered, but of these 5 were infants and could
not be satisfactorily examined, while the other was
sick at the time of examination. These 6 cases were
classed as apparent recovery. Forty-two cases had
partially recovered from paralysis, while 4 cases had
shown but very slight improvement since the attack. |
|
Deaths |
|
There were 5 fatal cases, 1 of which made a
partial recovery and died two months later of
bronchopneumonia. The length of the illness in days
was as follows: Female eight months, sixty-five
(broncho-pneurnonia); male three years, six; female
four years, four; female fifteen years, five; male
nineteen years, six. |
|
Age
And Sex |
|
Forty-two were males and 27 were females. This
epidemic was characterized by the number of cases in
middle and late childhood and young adult life. It
will be noticed that there were 6 cases over
seventeen years of age all in males. The following
table shows the age and sex of each case: |
|
Age |
Male |
Female |
Total |
<1 |
2 |
5 |
7 |
1 |
1 |
4 |
5 |
2 |
5 |
4 |
9 |
3 |
7 |
1 |
8 |
4 |
5 |
3 |
8 |
5 |
0 |
2 |
2 |
6 |
2 |
1 |
3 |
7 |
5 |
1 |
6 |
8 |
2 |
0 |
2 |
9 |
1 |
1 |
2 |
10 |
1 |
1 |
2 |
11 |
0 |
0 |
0 |
12 |
1 |
0 |
1 |
13 |
1 |
0 |
1 |
14 |
2 |
0 |
2 |
15 |
0 |
2 |
2 |
16 |
0 |
1 |
1 |
17 |
0 |
1 |
1 |
18 |
1 |
0 |
1 |
19 |
2 |
0 |
2 |
20 |
1 |
0 |
1 |
21 |
1 |
0 |
1 |
22 |
1 |
0 |
1 |
23 |
0 |
0 |
0 |
24 |
0 |
0 |
0 |
25 |
1 |
0 |
1 |
|
|
|
|
Totals |
42 |
27 |
69 |
|
|
School |
|
As the outbreak occurred in July and August,
there were no results that could be attributed to
school influences and but 3 of the children attended
school. |
|
Local
Conditions |
|
Investigation of the home conditions of each case
shows that sanitary conditions were found to be
excellent in 4 cases, good in 17, fair in 31 and bad
in 17. |
|
Forty-one of the cases lived in detached houses,
17 in two-tenement and 3 in three-tenement houses,
while but 8 lived in houses having four or more
tenements. |
|
The elevation of the dwelling was noted as high
in 28 cases, as medium in 22 and low in 19. |
|
Forty-two of the houses were considered to be
dry, while 27 were noted as being in a more or less
damp location. There were cellars in all of the
houses, 42 of which were dry and 23 were damp, while
4 were found to be very damp or wet. |
|
The water supply was given as spring water in 53,
as the town supply in 14 and from wells in but 2
cases. |
|
The sanitary arrangements in the houses showed
that 23 houses had water closets connected with the
sewer and 46 had earth closets; that the sink water
from 30 houses was carried into the sewer and in 39
cases it was disposed of in various ways on the land
nearby or in pipes to the nearest brook, pond, etc. |
|
Screens were found to be used in 65 cases and not
used in but 4 cases. Inquiry into the question of
flies and mosquitoes showed that flies were said to
be numerous in 28 instances, few in 39 and not
present in 2; that mosquitoes were said to be
numerous in 22 instances, few in 45 and not present
in 2. No history of insect bites at the time of
illness was obtained. |
|
Summary |
|
We are dealing with groups of cases of an acute
disease attacking children chiefly, but youth and
adults frequently up to the age of twenty-five years,
among the inhabitants of river valleys in
sparsely-settled communities, occurring during the
summer months of a hot, dry season. The persons
attacked lived chiefly in detached houses and but
eight lived in houses or blocks of more than three
tenements. Although the cause of the disease is not
known, it can undoubtedly be classed as infectious,
as its distribution and incidence in localities are
similar to those of other infectious diseases and
strongly suggest a common cause. |
|
Ninety per cent of the persons attacked were in
good health, and while a few instances of traumatism,
over-heating, fatigue and swimming were noted
previous to the onset, the history of these cases
does not seem to warrant the placing of much
etiological responsibility upon these occurrences.
They were not different from what might be found in
the history of almost any groups of persons at this
season. |
90% of the
polio cases were healthy people (with
well-functioning immune systems). |
With regard to the contagiousness of the disease,
the investigation of this group of cases suggests
that the disease is but mildly contagious to say the
most. A large number of children were in intimate
ontact with those that were sick, and of these
children an insignificant minority developed the
disease. Although the group of cases investigated is
a small one from which to draw generalizations, it
must be remembered that the circumstances were
particularly favorable to the investigation of points
of contact between sick and well and of the detection
of contagion. |
|
The sanitary conditions under which most of the
cases lived were not good. Dampness prevailed in many
locations. Most of the houses were very near water,
but it must be remembered that the outbreak was in
the valleys. Most of the houses had no sewer
connection. |
|
The marked digestive
disturbances, which were early and notable symptoms,
suggest the stomach as the port of entry for the
infection. It does not seem possible in this outbreak
to blame the varied sources of milk or water supply
as a carrier of the infection, unless it be
considered that the cause of the disease may be
present in all milk or in all water. That the cause
may be connected with the food seems possible.
It is important to note that none of the
seven infants under one year of age were fed
exclusively upon breast milk. |
Stomach
is portal of entry. Milk and water could be carrier
only if there were a causal agent in milk and water.
No victim under 1 year of age was fed exclusively on
breastmilk. The only positive correlations are milk,
water, and food. Breastmilk is out. |
The fact that all the cases living on the hill
farms had been in the valley towns recently where
infection may have occurred and that many families
purchased some of their food supplies from
peddlers’ carts which act as the go-between
between the town and the country, may be noteworthy. |
|
It is not known what influences the dry season
with its low water and the proximity of many of the
houses to water contribute, but these facts appear to
be significant. |
Slow
flowing streams means higher concentrations of
pollutants in the waterways. Polluted streams may
seep into groundwater and thus into wells. |
Conclusions |
|
From an intimate
acquaintance with all the facts and
conditions of this outbreak we conclude that |
|
1) |
Infantile paralyis is a disease produced
by some external agent; that is, it is an
infectious disease. |
|
2) |
That it is mildly contagious at the most. |
|
3) |
That the harmful agent appears to enter
the digestive tract in most instances. |
|
4) |
But that until the organism causing the
disease is known, it would be impossible to
say whether the infection is carried directly
to the patient or by means of food. |
|
Herein
it is admitted that the causal "organism"
is unknown and that the disease shows little evidence
of contagion. This patternless appearance of cases is
the description of mass poisoning, however, with
bias, the language of germ theory is strictly used,
and there is a total abscence of toxicological
considerations. The message is: Toxic cause for polio
is unthinkable.
It inconceivable that the health inspector would even
think to continue his investigation of the victims
and their circumstances with a toxicological
investigation, tracking the etiology of this
epidemic, searching for the upstream source,
interviewing and investigating the various industries
that were upstream, asking workers and owners what
and when they are dumping into the streams and
rivers.
Factories are regularly situated by waterways for the
purpose of being able to dump waste products, and for
transportation. Living downstream is a risk. There
was ample reason to perform a toxicological
investigation -- high-volume carbon-tetrachloride
production began in the U.S. in 1907. In 1908
carbon-tetrachloride was used as a fumigant in grain
silos, etc. It was also used to extract cotton seed
oil, probably in the Colrain cotton mills, which was
at the geographic center of the epidemic, where the
highest density of poio cases occurred, in this 1908
Massachusetts polio epidemic in Franklin County. |
|
Dr.
Scobey comments on this epidemic (see Endogenous
Virus? and ) |
Footnotes: |
1) |
This type of the disease
is recognized and described by Wickman. |
|
|