COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD, HX64166147 RJ496.P2 G76 A note on the presen RECAP Robert Graham A note on the presence of B, Botulinus T./p© A in the excretions of poliomyelitis patients • m Ii^1f6 f^ CotamWa 59nit)em'tp COLLEGE OF PHYSICLANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/noteonpresenceofOOgrah UNIVERSITY OF ILLINOIS BULLETIN Vol XIX ISSUED WEEKLY October 17, 1921 No. 7 [Entered as aecond-class matter December 11, 1912, at the post office at Urbana, Illinois, under the Act of Avigust 24, 1912. Acceptance for mailing at the special rate of postage provided for in section 1103, Act of October 3, 1917, authorized July 31, 1918. J A NOTE ON THE PRESENCE OF B. BOTULINUS TYPE A IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS By ROBERT GRAHAM and EDGAR BARGER Laboratory of Animal Pathology and Hygiene PUBLISHED BY THE UNIVERSITY OF ILLINOIS URBANA NOVEMBER 9, 1921 A NOTE ON THE PRESENCE OF B. BOTULINUS TYPE A IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS By ROBERT GRAHAM and EDGAR BARGER Laboratory op Animal Pathology and Hygiene PUBLISHED BY THE UNIVERSITY OF ILLINOIS URBANA NOVEMBER 9, 1921 il -^ I IY^> &n Epidemiologic Map I Outbreaks of Poliomyelitis in Illinois, Jan 1, 192/, to October 31, 1921. Data furnished by State Board of Health. Total number of cases, 463. Number of patients from which specimens were secured by the Laboratory of Animal Pathology and Hygiene, Univer- sity of Illinois (indicated by red dots), 87. Single circle indicates location of patients excretions of which proved positive. Double circle indicates location of patients excre- tions of which proved positive but which arc not discussed in this leaflet. A NOTE ON THE PRESENCE OF B. BOTULINUS TYPE A IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS By EOBEET graham and EDGAE BAEGE'E, Laboratory of Animal Pathology and Hygiene, University of Illinois Thru the cooperation of health officials, hospitals, and practicing physicians of Illinois,^ specimens of excretions from children suffering from poliomyelitis have been submitted to the Laboratory of Animal Pathology and Hygiene for examination. Sterile containers were mailed to the attending physician and the samples of urine and feces as collected were cultured immediately upon arrival at the laboratory. The purpose of this leaflet is to record the presence of B. botulinus type A in one feces and two urines of children during the convalescent period of a poliomyelitis infection.' The bacteriologic studies here reported are limited to samples of urine and feces from cases diagnosed as poliomyelitis. The possibility of B. botulinus as a saprophytic contaminant of the alimentary tract of healthy children as well as the possibility of this microorganism being present in the normal genito-urinary tract is not disregarded in the preliminary investigations. Furthermore, the method employed in collecting specimens may not have sufficed to eliminate extraneous contamination. In any event, it seems a note- worthy fact that B. botulinus should be encountered in excretions from the human body, and even tho upon further study it should be established that this microorganism bears no relation to the neuro- tropic virus of poliomyelitis or an analogous symptom complex in children, the widespread character of B. botulinus in nature will be more fully understood. Poliomyelitis as an investigational problem came to our attention in connection with studies conducted during the past five years rela- tive to the etiologic character of certain obscure toxemic syndromes in domestic animals. The results of these studies have shown that ^ Grateful acknowledgment is hereby made for the helpfnl cooperation and assistance given by the Hlinois State and Chicago Boards of Health, as well as the Cook County and Durand Hospitals of Chicago, Dr. C. W. East, Dr. J. J. McShane, Dr. C. G. Appelle, Dr. W. E'. Schowengerdt, Dr. Butler, and many other practi- tioners of human medicine. ^ Since this report was written, three specimens of urine (188, 242, and 395) from three other convalescent cases of poliomyelitis have upon bacteriologic exam- ination revealed the presence of B. botulinus type A. The geographic locations of these three cases are indicated on epidemiologic MajJ I by a red dot surrounded by two circles. 4 University of Illinois Bulletin ' [November 9, botulism is a rather common disease thruout the Mississippi valley, affecting swine, chickens, cattle, sheep, and horses. (See Maps III and IV.) Notwithstanding the fact that Flexner and others working in the field of poliomyelitis have disregarded the possible relation be- tween spinal paralysis in farm animals and poliomyelitis in children, certain clinical and epidemiologic observations in animal botulism with special reference to poliomyelitis in children as it occurred in Illinois during the late summer months of 1921 failed to clearly and decisively eliminate the possible etiologic connection between all cases of poliomyelitis and botulism in animals. A knowledge of the varying symptoms of botulism in animals sug- gested that the clinical aspects of a botulinus intoxication in man might also vary markedly.^ The clinical analogy between spontaneous botulism in nursing lambs as it occurred in Champaign county, Illi- nois (1917), to poliomyelitis in children also suggested the possibility of a common etiologic factor. Furthermore, the resistance of the bovine species to contaminated rations pointed to the possible danger of milk from apparently healthy lactating animals consuming con- taminated grains and hays. Experimental data bearing on the rela- tion of B. botulinus and toxin in the feed of the healthy lactating animal to the presence of the virus in fresh milk apparently suggest an explanation of the sporadic occurrence of some cases of spontaneous botulinus intoxication in the nursing young animals. The specific toxic character of milk from apparently healthy animals ingesting definite amounts of botulinus virus can be occasionally demonstrated in guinea pigs. In one instance Dingman* rather definitely recorded the possible relation of the milk supply to the occurrence of a disease in children diagnosed as poliomyelitis (New York, 1916). In three widely separ- ated boarding houses patronizing the same milk dairy, cases of poliomyelitis were observed. In three other families in the community which w^ere furnished milk from the same supply no cases of poliomy- elitis occurred. An investigation revealed the fact that the milk was always boiled by the latter three families while the former three families used the milk raw. If Dingman was dealing with cases of botulism, other possible modes of transmission are obviously not ex- cluded in view of the fact that botulinus toxin and spores have been demonstrated in other foods as well as in the larvae of the Lucilia caesar and in the mature fly. ^ Eecently, this contention was confirmed in connection with an acute gastro- intestinal disturbance in children from eating fig newtons in one family and bread in another Avhich upon examination were found to contain B. botulinus type A. The symptoms were not analogous to known cases of botulism in adult persons. ^Dingman, J. C. New York State Journal of Medicine, 16, 589. 1916. 19^1] B. BOTULINUS IN THE EXCKETIONS OF POLIOMYELITIS PATIENTS 5 The possible significance of the experimental findings in the milk - of lactating animals consuming contaminated rations, if any, in rela- tion to the health of the milk-consuming public suggested the occur- rence of some disease of a cryptogenic etiology in man. The conjecture that such a disease might more often occur in children than in adults would naturally follow because of the dietary difference or varying tolerance of the two groups. A resume of the literature on prevailing paralytic diseases of children with particular reference to numerous reports on poliomyelitis and the modes of transmission presents a conception of poliomyelitis which conflicts with the disease as experi- mentally produced and fails to harmonize with the generally accepted ideas regarding other infectious diseases. In this connection the possibility of a food transmission is not entirely disregarded. These and other facts suggested the advisability of attempting a comparative study of poliomyelitis in children from the standpoint of pathogenic anaerobes, with particular reference to B. botulinus. Observations in animal botulism indicate that the symptomatology of a botulinus intoxication in children might not be easily recognized on the basis of the syndrome of this intoxication observed in mature persons. In fact, there has been no more perplexing problem in animal botulism than the clinical diagnosis of the disease, not only in different animal species, but in the same specie of different ages. If this phenomenon is subject to interpretation it may be explained on the basis that the toxin may affect or localize in different nerve centers and thus induce various forms of local paralysis. In view of the fact that a specific botulinus intoxication in animals has been clinically confused with acute bacterial infections, rabies, and defi- ciency diseases, it is even possible to suggest that the acute and more easily diagnosed cases of botulism in domestic animals and man con- stitute but one type of the existing, yet unrecognized, forms of this disease. The syndrome encountered in the classical picture of poliomyelitis as observed in different patients, however, suggested to the writers the possible presence of a neurotropic virus resembling the action of botulinus toxin. A CLINICAL AND EPIDEMIOLOGICAL NOTE OF THE POLIOMYELITIS PATIENTS Three of the cases of poliomyelitis in children, wherein B. botulinus type A was encountered in the excretions, were reported on the follow- ing epidemiologic cards of the Illinois State Department of Health : University of Illinois Bulletin [November 9, Fig. 1. — Patient 154 19S1] B. BOTULINUS IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS Patient 154 ILLINOIS STATE DEPARTMENT OF HEALTH COUNTY CITY OR TOWNSHIP NAME DATE Sept. 12, 1921. OUTBREAK IN FAMILY POLIOMYELITIS Years MaI<^FemaTe Marfied"SinEl..^Widowcd White— Black ADDRESS: STREET NUMBER FLOOR 1 ROC (Of Molhcr. if minor) REPORTED BV DP . ZOCl 8 D. LUHlley ADDRESS „.,, sept, 13, 1921. THE HOUSE, OENERAU CONDITION PBIT NUM BER OF FAMILIES 1 STABLE NEAR7,VESMNO, ^66 EXPOSED OARBA3E. ETC.. NOTED, , VES) . NO, YeO THE HOME, GENERAL CONDITION (OOODl(BAD> Pair PLIES iVES, .NO, YSS VERMIN (VES, (NO, No THE PAMILY, ADULTS O CHILDREN 2 J. ON PRE MisEs SINCE 1 month C, — ^ years 6 — 10 years 11— 20 years DETAILS. DATES OP CONTACT INSPECTORS DIAGNOSIS Acuto suterlor poliomyelitis ONSET DATE Sept. 12th PARALYSIS, WHEN FIRST APPEARED Sept. 1 3 , PARTS AFFECTED ISft 8 riD GENERAL SYMPTOMS, RESPIRATORY NO GASTROINTEST NAL No TYPE- 1 ABORTIVE 2 SP 1 NAlV 6 S 3 MENl NGEAL -ICEREBRAL LUM BAR PUNCTURE DATE "No RESULT PRECAUTIONS OBSERVED, ISOLATED (YES, NO, YBS DEATH HO FROM FOOD HANDLERS IN FAMILY (YES, (NO, REPORT NO CH 1 LOR' N ATTEND SCHOOL AT EXCLUDEoYeS REMOVAL AND RENOVATION ORDERED YeS-SCreenS ASSIGNEDTO D P . H eBry RO i 3 , BS 1 IC Vl 1 IS RETURNED Anamnesis Sept. 6 — Child indisposed. Vomiting and pains in epigastrium. Sept. 10, 11 — Slight headache. Sept. 12 — Headache, tackache, pain in right arm. Sensation in left arm, described as ' ' worms crawling inside of arm. ' ' Sept. 13 — Left arm showed paralysis of long flexors and shoulder muscles. Slight constipation relieved by mild cathartic. Diagnosis: Poliomyelitis Urine as submitted in sterile container Sep- tember 20, 1921, proved positive to B. botulinus type A. University of Illinois Bulletin [Novemher 9, PM 19£1] B. BOTULINUS IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS Patient 269 ILLINOIS STATE DEPARTMENT OF HEAL,TH countW CITY oR'VawraS H TV NAME DATg SOpt . 14 > 1921 OUTBREAK IN FAMILY POLIOMYELITIS AGESOmOseX P MARITAL STATE S COLOR W NATIONALITY D.S/ . OCCUPATION ADDRESS: STREET WOSteni AVO , NUMBE Tlif"^ FLC^Tt"" ROOM"'NO°:'6':"°""cAREOFDr.Butler: REPORTED BY H^O* THE HOUSE: GENERAL CONDITION Pa"lr" NUMBER OF FAMILIES , 1 ' STABLE NEAR, (YESMNO, flO , EXPOSED OARBAG I. ETC.. NOTED, ;yES, .NO, QQ THE HOME, GENERAL CONDITION (GOODl IBAD, P FLIES lYES. (NO, nO_J VERM 1 N ( YES, ( NO, 'llO THE FAMILY: ADULTS O CHILDREN 1' ON PREMISES SINCE 3 ySaTS EXPOSURE TO INFECTION: ANY CONTACT. DIRECT OR INDIRECT. WITH OTHER CASE? (YES) (NO) ^ DO DETAILS. DATES OF CONTACT INSPECTORS DIAGNOSIS Acutc aiiterlor poliomyelitis onset: date 9-3-21 PARALYSIS WHEN FIRST APPEARED 9-9-21 PARTS AFFECTEoRight& left, upper & lower extremities GENERAL SYMPTOMS RESPIRATORY yS3 gastrointestinal yes TYPE: . ABORTIVE ^ SP, NAL JSB 3 MEN, NGEAL =NO. REPORT NO CHILD F?JN ATTE VD SCHOC L AT LAND RENO NATION ORDERED ASS.GN ED TO s.s. Winner M.D. RETURNED Anamnesis Sept. 16— Cheeks flushed. Sept. 17 — Patient vomiting, high fever, irrational, grinding teeth. Spasmodic twitching of hands, constipation, pain in lumbo-sacral region and posterior muscles of left leg. Headache and pain over left eye. Patient in attempting to stand fell over. Sept. 19 — Pupils dilated, facial and neck muscles normal. Well marked posterior and cervical adenopathy. Temperature 101°. Spasmodic twitching of pectoralis. Partial paralysis of lower left extremity. Diagnosis: Poliomyelitis Urine as submitted in sterile container Septem- ber 27, 1921, proved positive to B. botulinus type A. 12 University of Illinois Bulletin [Novemher 9, Ph ^ P^ fj 1931] B. BOTULINUS IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS 13 THE RELATION OF STRAINS 154, 269, AND 276 TO B. BOTULINUS TYPE A Ten days after the urine and stool inoculations (154, 269, and 276) were made, the cultures were tested for toxicity by feeding .5 cc to healthy guinea pigs. The toxic effect of cultures 269 and 276 was first noted twenty-four hours after feeding. On the second morning the photographs shown in Figs. 4 and 5 were made, and within a few hours, forty-eight hours after the feeding of the toxin, the pigs were dead. The prostrate condition as observed in these animals is typical of botulinus intoxication in guinea pigs. Death in animals so aftectea generally follows in a few hours. The lethal character of the cultures isolated from specimens 154, 269, and 276 to type A botulinus was demonstrated by injecting ex- posed guinea pigs with antitoxin. The results encountered in culture 154 are identical with those obtained from culture 276. Culture 269 produces a very mild extra-cellular toxin. On October 4, 1921, three guinea pigs were given .5 ec of broth culture 154 via the mouth. Simultaneously pig 76 was given subcutaneously 25 units of botulinus antitoxin type A, and pig 780 was given subcutaneously 25 units of Table 1 G.P. Toxin 10-4-21 Antitoxin 10-4-21 Eesults 76 154 — .5 cc per orem 25 units botulinus anti- toxin type A, subcutaneously Remained healthy 780 154 — .5 cc per orem 25 units botulinus anti- toxin tyi^e B, subcutaneously Dead 10-5-21 308 154 — .5 ec per orem Control Dead 10-5-21 Fig. 6. — Guinea Pigs 76, 780, and 308, Showing Protective Character of Type A Antitoxin. Photograph Taken Twenty-four Hours after Treatment 14 University of Illinois Bulletin [Novemier 9, botulinus antitoxin type B. Pig 308 was left as a control. The treat- ment as administered and the result are presented in Table 1. In Fig. 6 is shown a photograph of the guinea pigs taken twenty-four hours after the treatment. The immunologic relation of culture 154 to culture 276 was estab- lished by a similar procedure wherein the protective character of botulinus antitoxin type A was observed. The toxin and antitoxin were administered as indicated in Table 2. As shown in this same table, the pig which had been injected with botulinus antitoxin type A was the only one of the three which survived at the end of twenty-four hours. See Fig. 7. Table 2 G.P. Toxin 10-21-21 Antitoxin 10-21-21 Eesults 856 276 — .5 ee per orem 25 units botulinus anti- toxin type A, subcutaneously Eemained healthy 725 276 — .5 cc per orem 25 units botulinus anti- toxin tyx^e B, subcutaneously Dead 10-22-21 124 276 — .5 cc per orem Control Dead 10-22-21 Fig. 7. — Guinea Pigs 856, 725, and 124, Showing Protective Character of Type A Antitoxin. Photograph Taken Twenty-four Hours after T'reatment The toxogenic character of strain 276 for monkeys was observed by feeding the contents of one glucose agar shake culture to a healthy ringtail monkey (white-throated Sapajou or Capuchin, Cehus liypo- leucus, No. 734). The culture was fed at 11 a.m., October 22, and the animal then placed in a separate cage and fed wholesome food. Pro- found toxic symptoms were observed at 7 a.m., October 24. At this time the monkey was able to stand erect for only a moment. An opossum-like attitude (Fig. 8) was assumed as the pendulous head 16 University of Illinois Bulletin yNovember 9, Fig. 8 Fig. 9 1931] B. BOTULINUS IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS 17 Fig. 10 Fig. 11 Figs. 8-11. — Symptoms Observed in Monkey 734 Forty-five Hours after Exposure 19^1] B. BOTULINUS IN THE EXCRETIONS OF POLIOMYELITIS PATIENTS 19 and neck (Figs. 9 and 10) flexed on the forearms. When placed in a standing position with the head erect, the animal fell over and assumed a lateral decumbent position (Fig. 11). The respirations were shallow and irregular. Following exertion, dyspnea and mouth-breathing were pronounced. Complete prostration and coma terminated in respira- tory paralysis and death at 11 a.m., October 24. SUMMARY Approximately two hundred specimens of body excretions includ- ing feces and urine as well as throat swabs from some eighty cases of poliomyelitis are being examined in the Laboratory of Animal Pathology and Hygiene of the University of Illinois, for pathogenic anaerobes. One stool and five urines as submitted from widely sepa- rated spontaneous cases of this disease in the state of Illinois have proved positive to B. botulinus type A. The syndrome in each of the six cases was regarded as typical of poliomyelitis by the attending physician. Since other possible factors have not been considered in the pre- liminary studies, the specific relation of -B. botulinus type A to poliomyelitis-like diseases is only a matter of conjecture at this time. Furthermore, the number of cases of poliomyelitis in children included in this phase of the investigation is too small to permit the conclusion that B. botulinus is an etiologic factor. However, the possibility of a botulism transmission thru milk is experimentally established in ani- mals, and if the human organism reacts similarly, milk may be a factor tho the possibility of transmission thru other foods merits con- sideration. The role of flies or other insects which might mechanically contaminate food, is not excluded in the preliminary studies. In view of these facts, as well as of the neurotropic character of botulinus toxin, it seems advisable not to overlook the possible relation which may exist between some cases of poliomyelitis in children and a spe- cific botulinus intoxication, altho the occurrence of distinct and sep- arate diseases in children, diagnosed as poliomyelitis, is not excluded in this connection. The fact that B. botulinus type A has been encountered in the excreta of six convalescent poliomyelitis patients suggests the advisa- bility of continuing the investigations until the saprophytic and toxo- genic character of this microorganism in nature is definitely established with special reference to its presence in the excretions of normal chil- dren and of patients suffering from a paralytic syndrome. 5t. Clair Mo. Marshall. Mo. Clarksburg, fia Kansas City, Mo. Indianapolis. Ind. Battk Creek, Mich. Grand Bapids, Mich. Wash inqfon. DC. " Freehold, N.J. ' Epidemiologic Map II Total number of contaminated feeds or outbreaks of botulism in man and animals confirmed by baeteriologie and immunologic examinations in the Laboratory of Animal Pathology and Hygiene, University of Illi- nois, Sept. 1, 1920, to Sept. 1, 1921. In Illinois, 149. Outside of state, 9. 20 Epidemiologic Map III Swine botulism confirmed by bacteriologic and immunologic examination in tlie Labora- tory of Animal Pathology and Hygiene, Uni- versity of Illinois. Sept. 1, 1920, to Sept. 1, 1921. 21 Epidemiologic Map IV Outbreaks of avian botulism confirmed by bacteriologie and immunologic examinations in the Laboratory of Animal Pathology and Hygiene, University of Illinois. Sept. 1, 1920, to Sept. 1, 1921. 22 Indiana lov/a Kentucky Minnesota Missouri Washington. DC- Z Epidemiologic Map V 2505 specimens submitted to the Labora- tory of Animal Pathology and Hygiene, Uni- versity of Illinois, for bacteriologie, path- ologic, and seriologic diagnosis. Sept. 1, 1920, to Sept. 1, 1921. 23 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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