LIBRARY NEW YORK STATE VETERINARY COLLEGE ITHACA, N. Y. Digitized by Microsoft® Cornell University Library RJ 496.P2P35 A Clinical study of acute poliomyelitis. 3 1924 000 324 784 Digitized by Microsoft® This book was digitized by Microsoft Corporation in cooperation witli Cornell University Libraries, 2007. You may use and print this copy in limited quantity for your personal purposes, but may not distribute or provide access to it (or modified or partial versions of it) for revenue-generating or other commercial purposes. Digitized by Microsoft® <\\ Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archivfi.pra/delails/cu31924000324784 " DiQiTizea b y Wiicrosoff® I'Jby Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® A CLINICAL STUDY OF ACUTE POLIOMYELITIS BY FRANCIS W. PEABODY, M.D., GEORGE DRAPER, M.D. AND A. R. DOCHEZ, M.D. Digitized by Microsoft® ■ i \ •' n ^ ^ /\ \' *^ - Digitized by Microsoft® MONOGRAPH OF THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH. NUMBER 4. JUNE I, I9I2. A CLINICAL STUDY OF ACUTE POLIOMYELITIS. By FRANCIS W. PEABODY, M.D., GEORGE DRAPER, M.D., AND A. R. DOCHEZ, M.D. {From the Hospital of The Rockefeller Institute for Medical Research, New York.) Plates 1-13. CONTENTS. Page, INTRODUCTION 2 HISTORICAL 4 EPIDEMIOLOGY 7 NEUTRALIZATION TEST 14 PATHOLOGY 15 SYMPTOMATOLOGY 27 Clinical Classification of Cases 27 Predisposing Causes 30 Prodromal Period 32 Bulbospinal Type 39 ACUTE stage 39 paralyses 48 Cerebral Type 73 ABORTIVE TYPE 77 THE BLOOD 80 THE CEREBROSPINAL FLUID 98 PROGNOSIS 108 TREATMENT iiS CASE HISTORIES 122 The following study is a report of the work on acute polio- myelitis carried on at the Hospital of The Rockefeller Institute for Medical Research during the summer of 191 1. The material con- sisted of one hundred and sixty-one cases which occurred during the present season and twenty-two cases from previous years. Seventy-one of these cases were admitted to the hospital and were Digitized by Microsoft® 2 A Clinical Study of Acute Poliomyelitis. under observation for a period averaging from three to four weeks. The other cases were seen in the dispensary. The study was chiefly of a biological nature, and, on account of lack of time, observations of the disturbances of the reaction of the muscles to electrical stimulation were used for diagnosis and prognosis to a limited extent only. We have attempted to correlate our experience with that of other observers, but no effort has been made to give a complete review of the literature. For a complete bibliography we refer the reader to the articles and monographs on which we have drawn freely.^ INTRODUCTION. The recognition of poliomyelitis as an acute infectious disease was delayed largely owing to the strange relationship between the ■obscure, inconsequential features of the early stage and the flagrant character of the resultant paralyses. In most text-books, descrip- tions of the disease as an acute infection dismiss the fever and initial malaise in a few lines, while the diagnosis is declared easy because of the sudden and complete paralysis. The following words from Allbutt's System of Medicine (1905) are significant: "... and after two days, when the pain had passed away, the case was found to be one of infantile paralysis. The fever and general constitutional dis- turbances at the onset had obscured the diagnosis." Furthermore, as a result of the earlier pathological studies of infantile paralysis. "Romer, P. H., Die epidemische Kinderlahmung, Berlin, 1911. Wickman, Ivar, Beitrage zur Kenntnis der Heine-Medinschen Krankheit, Berlin, 1907; Die akute Poliomyelitis, bzw., Heine-Medinsche Krankheit, Berlin, 1911. Zappert, von Wiesner, and Leiner, Studien tiber die Heine-Medinsche Krank- heit, Leipzig and Vienna, 191 1. Miiller, E., Die spinale Kinderlahmung, Berlin, 1910. Harbitz and Scheel, Pathologisch-anatomische Untersuchungen iiber akute Poliomyelitis und verwandte Krankheiten, Christiania, 1907. Flexner, The Contribution of Experimental to Human Poliomyelitis, Jour. Am. Med. Assn., igio, Iv, 1105. Massachusetts State Board of Health, Infantile Paralysis in Massachusetts in 1909, Boston, 1910. Epidemic Poliomyelitis. Report on the New York Epidemic of 1907 of the Collective Investigation Committee, New York, 1910. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 3 made chiefly upon cases that died later from other causes, the term atrophic was added to the obscuring nomenclature of the disease. The changes noted in the spinal cord were scar formations in the anterior horns, and no lesions were found elsewhere in the body. Consequently, attention was focussed on certain chronic changes in a limited portion of the spinal cord. From the practitioner's stand- point, the natural course of the malady is such that his efforts have been palliative rather than curative. Usually he is called to face, helplessly, a child recovering from a febrile disturbance, but stricken with an amazing paralysis. The crippled state of the patient be- comes the all-engrossing feature of the case, and the physician's chief effort is to devise methods of support and artificial activity. The management of this disease, therefore, has become a problem for the orthopedic surgeon ; the internist is too late. Fortunately, however, the work of the past few years on the experimentally produced disease, and, above all, the fine accounts of the human affliction by Wickman, Muller, and others have been most illuminating. It has become clear that the first outward expression of the disease is the fever, and in order that the subsequent paralyses may surely be prevented, the infecting agent must be destroyed before it has called forth a damaging reaction in the body. In the event of possible means of treatment in the future, therefore, early diagnosis is imperative, and in view of the obscure and often in- significant mode of onset, the problem becomes one of great diffi- culty, which calls for the best qualities and equipment of the internist. In those very symptoms of onset, the fever and general constitutional disturbances, which have been said to obscure the diagnosis, lie the warnings which should arouse the physician at once to such special procedures as are known to be helpful in making the diagnosis. Besides the importance to the affected individual, the recognition of acute poliomyelitis in its febrile stage has a serious bearing on the community at large. It has been definitely shown that there are many obscure cases that never develop paralysis, whose mild symptoms indicate no specific infection, but which may carry and spread contagion. Just what proportion of all cases these abortive cases form is still a doubtful point. In the large epidemics, where Digitized by Microsoft® 4 A Clinical Study of Acute Poliomyelitis. physicians are expectant, the reported number of such cases is rela- tively larger than among a series of sporadic instances of the disease. At all events, it seems evident that abortive cases play a most important part in the total incidence of the disease; and in con- nection with their great frequency, it must be borne in mind that the virus is probably present in these cases in as active a form as in the patients with paralysis. In view of these considerations, it is obviously a matter of great importance to determine the relative frequency of the abortive forms of the disease, and to recognize them, for it is these cases which, not being recognized, escape quar- antine and spread the virus. In general, the cases that develop no paralysis are clinically similar as regards history, prodromata, and onset, to those that go on to disability. Early diagnosis, therefore, serves a double purpose. The individual may, with an effective therapy, be spared a paralytic visitation, and the community may be protected from the menace of an unrestricted virus carrier. The purpose, then, of the following pages is to emphasize the fact that poliomyelitis is an acute disease, in which the often insig- nificant febrile stage is of high epidemiologic and therapeutic im- portance. HISTORICAL. During the past seventy years infantile paralysis, or acute polio- myelitis, has been gradually separated from a mass of heteroge- neous palsies and established as a pathological and clinical entity. ■Although between forty and fifty epidemics have been described, it is a striking fact that the first three important milestones on the path of our advancing knowledge of the malady are separated by long intervals of time. In 1840, Heine,^ an orthopedic surgeon of Cannstadt in Ger- many, published a monograph on paralytic conditions of the lower extremities and their management. The chief stress of the work is laid upon the surgical aspect of the disease, but there is a short, clear cut description of the onset and acute stage. For etiology, "Heine, Jacob, Beobachtungen fiber Lahmungszustande der untern Extrem- jtaten und dteren Behandlungen, Stuttgart, 1840; Spinale Kinderlahmune Stuttgart, i860. Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 5 a sudden serous exudation in the spinal cord is suggested, and a rough description of spinal cord changes indicates the author's idea of the site of the lesion. The work of Heine is a fine example of keen clinical observation and leaves no doubt of the correctness of his view that the disease is an entity. Except for an epidemic described by Colmer,* there is little more of clinical importance in the literature of poliomyelitis for the next forty years. Charcot,* in 1870, studied the pathology of poliomyelitis and declared a pri- mary degeneration of the anterior horn cells to be the morbid process. This view has been the subject of much discussion. In 1884, StriimpelP pointed out the resemblance between certain cases of acute encephalitis with spastic paralysis in children and cases of poliomyelitis. He concluded that these two types of disease of the central nervous system had a common etiological factor, and sug- gested for the first time the hypothesis that an external infectious agent was responsible for them. His recognition of the true cere- bral form of the disease was a most important contribution to the knowledge of poliomyelitis. During the numerous epidemics re- ported in the following years, many instances of apparently direct contagion were observed, which added support to Striimpell's sug- gestion. There was still lacking, however, a description of the symptomatology of the disease in its complete cpurse. In 1890, Medin,® basing his studies upon the extensive Swedish epidemics, published the first good clinical account of acute polio- myelitis. Medin's work is perhaps as much of a classic as Heine!s, and his name has been coupled with the latter's in association with the disease. He likewise described the spastic types of poliomyelitis which had been recognized by Striimpell as occurring in association with the usual forms. Following this, almost each year saw reports of smaller epidemics in France, Italy, Germany, and the United States ; but no important additions to the existing knowledge of the disease were made, until Wickman,^ in 1905, studying a vast amount ' Colmer, Am. Jour. Med. Sc, 1843, v, 248. * Charcot, quoted by Oppenheim, Lehrbuch der Nervenkrankheiten, Berlin, 1908. ' Striimpell, Jahrb. f. Kinderheilk., 1884, xxii, 173. ' Medin, Verhandl. d. X. internat. med. Cong., 1890, ii, 6 Abt., 37. ' Wickman, Beitrage zur Kenntnis der Heine-Medinschen Krankheit, loc. cit. Digitized by Microsoft® 6 A Clinical Study of Acute Poliomyelitis. of material in Sweden, developed the epidemiology of the disease and its pathology, and described for the first time the abortive types. The importance of this particular contribution will become more evident in the discussion of the epidemiology. Wickman's ex- haustive studies demonstrated conclusively the contagious nature of the disease. There remained, therefore, the problem of finding the infecting agent. Experimental production of the disease in monkeys was first accomplished in 1909 by Landsteiner and Popper,® and a few months later by Flexner and Lewis^ and by Strauss^* in this country. Three observers in different cities independently succeeded in trans- ferring the disease from one monkey to another. This was done in November, 1909, by Flexner and Lewis in New York, Leiner and von Wiesner^^ in Vienna, and Landsteiner and Levaditi^* in Paris. The reports from the various sets of workers appeared within a period of two weeks. As a result of the extensive work which has been done on the experimental disease, many important facts about the etiology have been acquired. A bacterial cause has been definitely ruled out and there is now undoubted evidence that the infecting agent belongs to the group of so-called filterable viruses.^* The virus of polio- myelitis is highly resistant to many destructive measures; thus, it withstands glycerination for long periods and is not injured by 0.5 per cent, carbolic acid. Furthermore, freezing at — 2° to — 4° C. for forty days does not affect it materially. To heat, it is less resistant and it can be destroyed by a temperature of 45° to 50° C. for half an hour. The virus is readily destroyed by hydrogen peroxide in 2 per cent, solution, by menthol, and by corrosive sublimate. In monkeys, one attack of the experimental disease pre- vents a second successful inoculation. Fairly satisfactory results in the production of active immunity, induced by repeated injections of small amounts of attenuated virus, have been obtained, but these * Landsteiner and Popper, Ztschr. f. Immunitdtsforsch., Orig., 1909, ii, 377. ° Flexner and Lewis, Jour. Am. Med. Assn., 1909, liii, 1639. " Strauss and Huntoon, N. Y. Med^ Jour., 1910, xci, 64. "Leiner and von Wiesner, Wien. klin. Wchnschr., 1909, xxii, 1698. "Landsteiner and Levaditi, Compt. rend. Soc. de bid., 1909, Ixvii, 592. ^'Landsteiner and Levaditi, loc. cit.; Flexner and Lewis, Jour. Am. Med. Assn., 1909, liii, 2095. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Doches. 7 have not warranted the application of this procedure in man. The serum of recovered monkeys, and also the serum of human patients that have recovered from this disease, have been shown to contain a substance that is capable of neutralizing the virus in vitro. If o. I of a cubic centimeter of the active virus^* and one cubic centimeter of the serum of a case of poliomyelitis be mixed in a test tube, incu- bated for two hours at 37° C, refrigerated over night and then injected intracerebrally into a monkey, the animal does not have any symptoms of the disease. This neutralizing substance has also been demonstrated in the blood of abortive human cases. EPIDEMIOLOGY. The study of the epidemiology or mode of transmission of epi- demic poliomyelitis has been much promoted by the observations of Wickman in 1905, who first drew special attention to its contagious character. All subsequent studies have been influenced by the fundamental observations of Wickman, and have tended to support his deductions. An entirely new light was thrown on the obscure question of dis- semination by Wickman's recognition of the so-called abortive and meningitic forms or types of the affection. Until then, attentk)n had been riveted on the paralysis, and the possibility of cases of epidemic poliomyelitis occurring in which paralysis is entirely absent seems not to have been entertained. It is at once clear that the existence of such cases would throw an entirely new light upon the mode of transmission of the infection. That epidemic poliomyelitis must be an infective process follows from its epidemic character. We are unacquainted with any disease that flourishes in epidemics that is due to other causes than parasitic. That the infective cause finds a considerable degree of resistance naturally present in any community is proven by the strong tendency of the frankly paralyzed types of the disease to appear as isolated cases in a given family or household. But this is merely a tendency, since the occurrence of dual and even multiple infection in one household is by no means uncommon. Indeed, now that the abortive and meningitic forms of the affection, without paralysis, " The active virus, so-called, is merely a filtrate of a 5 per cent, salt solution suspension of the spinal cord of an infected and paralyzed monkey. Digitized by Microsoft® 8 A Clinical Study of Acute Poliomyelitis. are acknowledged, the instances of multiple cases are not so infre- quent as they were believed to be. To demonstrate that more than one case may frequently occur in the same family, the following three instances are significant. Two of these involve bottle-fed infants, the other deals with older children. Family /.—Belle and Clara T., twins, eight months old. Belle T. Feverish, August i8; next day temperature 103° F., throat red and inflamed, slight patch on the right tonsil; patient nervous; breathing rapid;' pneumonia suspected. August 20, child less nervous and began to seem dull. August 21, twitching of face and athetoid movements of foot; later in the day weakness in left arm and leg. August 23, involvement of respiratory muscles; death. Clara T. August 21, child irritable, vomited several times, and coughed. August 22, temperature 102° F., vomited several times ; examination of right leg caused unusually loud screaming; slight weakness in right thigh. August 23, paralysis definite. Here is a situation where twin infants were infected so nearly synchronously that it is impossible to say whether one case con- tracted the disease from the other, or whether a common source provided the virus for both. The fact that both infants were bottle- fed makes infection by interchange of nipples conceivable. The next example of family contagion also presents a somewhat similar situation. Family II. — Margaret W., age fourteen months, began on October 4 to have typical symptoms of onset and in three days developed incomplete paralysis of both lower extremities. Four days later her infant sister became feverish and looked sick. Two days later the latter was brought to the hospital with begin- ning paralyses which advanced rapidly and terminated fatally by involvement of the respiratory muscles. The mother said that this child had frequently been put in the same bed with the older one, and that she had seen the children alter- nately suck the nipple of the common feeding bottle. Family III. — Hannah T., age four years. On October I, she was well in the morning but vomited in the afternoon and was feverish. The next day she was paralyzed. There are four other children in the family, one older and three younger than Hannah. One week before her illness the older brother had had tonsillitis, and a day or two after his attack began, the three younger children had what the mother called a " drowsy sickness,'' in one case with fever. A small brother, one of the three, was brought to the hospital with typical symptoms of the acute stage of the disease and significant changes in his spinal fluid. There were no definite paralyses, but a distinct shakiness in walking was noticed. These family infections speak for themselves in the matter of direct contagion. The last instance, although lacking definite proof, Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 9 is highly suggestive of the importance of abortive cases. One further example, however, where the evidence of a neutralization test made probable the correctness of the diagnosis of acute polio- myelitis in a case that had no muscular weakness, is of interest at this time. Helen K., age three years and ten months. On August l6, she had headache and was feverish; on the l8th, paralysis of the legs began and ascended rapidly to the arms and terminated fatally by respiratory involvement on August 21. Her constant playmate, Helen B., age six years, had headache on September I, that is about ten days after Helen K. was ill, and the following day was brought to the hospital. Examination of the spinal fluid showed changes similar to ■those seen in poliomyelitis. She never developed paralysis and after fifteen days went home apparently well. Her blood serum' protected a monkey against O.I c.c. of the virus. This child had no definite symptoms beyond some stiffness of the neck, headache, apathy, and anorexia. Except for her close associa- tion with the fatal case, her mother would have paid no attention to "what might have passed as a slight summer ailment, and a diagnosis would never have been made. The child would have gone to school in a few days and perhaps have been the source of infection for ■other individuals. Human beings are very unequally subject to the effects of dif- ferent contagious affections. It is only smallpox and measles that can vegetate in any soil ; all other direct infections are conditioned by degrees of susceptibility of the host that determine the extent of their prevalence. Scarlet fever, typhoid fever, and epidemic menin- gitis can claim far fewer victims. Indeed, the degree of suscepti- T)ility, as determined by age and other circumstances, is strikingly similar in epidemic meningitis and epidemic poliomyelitis. Epidemic poliomyelitis has been clearly observed to follow the lines of human contact and travel. Wickman has placed the pri- mary center of infection and transmission in the village school, and the secondary centers he has traced to contacts that arise out of cir- cumstances of ordinary human intercourse. Through these, the in- fection is spread in a village and from one village to an adjacent ■one. Moreover, he has emphasized that the carrying of the infec- tion is twofold, by the affected and the non-affected, or, actively and passively, as one would now say. The most important active Digitized by Microsoft® 10 A Clinical Study of Acute Poliomyelitis. carrier of the epidemic is the victim of an abortive attack of the disease, since he may not be confined during any period and is as capable, probably, of distributing the infection as a case attended by paralysis. This is equally true of some other contagious diseases, notably diphtheria and scarlet fever. For in these diseases which are not highly contagious, as is measles, the healthy carrier has never been given much consideration; indeed it has been largely overlooked. This omission has been due to the high natural resistance possessed by the community. Attention is then to be fastened upon the human agency of trans- mission. This is all important because, if it is the true and most fre- quent agency, then preventive measures, effecting both limitation and final suppression, will be taken accordingly. The admission of this source of contagion will dispose of the vague notions regarding the existence of sources of infection among the lower animals. The following extract from a paper of Flexner's^® on the control' of epidemic poliomyelitis will serve to show the present state of knowledge and conjecture on this aspect of the problem : "Paralytic diseases among domestic animals are known and not highly infrequent. They have been noted among dogs, horses, and fowl, but thus far it has not been found possible to correlate the paralytic diseases of the lower animals and those of man. Perhaps the most frequently observed coincidental paralytic diseases have been between hens and human beings. Undoubtedly since the wide prevalence of epidemic poliomyelitis, the existence of a paralytic dis- ease among barnyard fowl has been more commonly noted. Pos- sibly the condition has not actually become more frequent, but owing to the circumstance mentioned it has been oftener observed. It would appear that the paralysis among fowl is caused not by lesions of the central nervous system, but by lesions of the peripheral nerves- and that it is due to a peripheral neuritis. It has not been found possible to transmit by direct inoculation the paralytic disease from chicken to chicken, or from chicken to monkey, or from paralytic monkey to chicken (Flexner and Lewis). However, it has been found possible to develop the paralysis in the laboratory by keeping the chickens in confinement for some time, and by supplyino- thenr '"Flexner, Am. Jour. Dis. Child., 1911, ii, 96. Digitized by Microsoft® Francis W. Peaiody, George Draper, and A. B. Dochez. 11 an unusual and doubtless improper form of food (Flexner and Clark). It has proved as little possible to transfer the paralytic affection of dogs from one individual to another by direct inocu- lation or from dog to monkey or from paralyzed monkey to dog (Flexner and Lewis). These failures do not, of course, exclude the possibility that a reservoir for the virus may exist among domesti- cated animals that do not even respond to its presence by developing paralysis or other conditions which could be recognized as resem- bling poHomyelitis in man. The manner of the action of the virus of poliomyelitis in rabbits provides an illustration which shows how necessary it is to avoid general deductions in this field. At first it was strenuously denied that rabbits could be infected at all with the virus of poliomyelitis, and the examples of supposed successful inoculation reported were entirely disbelieved (Krauseand Meinicke, Lentz and Huntemiiller) ; but it must now be accepted that young rabbits occasionally, but by' no means generally, are subject to inocu- lation with the virus of poliomyelitis, at least after it has passed through a long series of monkeys (Marks). Apparently a small percentage only of the inoculated rabbits develop any obvious symp- toms, and these die, as a rule, during convulsive seizures which come on suddenly. A given virus has up to the present been sent through a series of six rabbits, after which it has failed to be further propa- gated. From the sixth series it has been reimplanted on the monkey, in which animal typical paralysis has been produced (Marks). It remains to add that the rabbits which succumb to the inoculation do not show any characteristic lesion of the central nervous system or other organs, as far as has been determined. The monkey, on the other hand, invariably shows the typical lesions of the central nerv- ous system. " Insect contamination with the virus would serve, were it proved not only to be an experimental possibility but to occur in nature, to I clear away any present apparent discrepancies in the epidemiology of the disease. In this connection it should be stated that not only does epidemic poliomyelitis spread over a wide territory, but its spread is not promiscuous, but along the routes of human travel. Therefore insects that seek human habitations and routes of travel, Digitized by Microsoft® 12 A Clinical Study of Acute Poliomyelitis. that possess the power to migrate over a considerable territory, that affect all classes of society, that abound during the period of greatest prevalence of the disease, and that do not wholly disappear at any season, should be the first to come under suspicion. Many, if not all, of these conditions are fulfilled by the common house-fly." The effort to make out a case for insect transmission has, how- ever, failed up to the present. The part that the house-fly may play in the transfer of the virus is strictly passive. That these insects can carry the virus in a living and actively infectious state for forty- eight hours or longer has been proven by the laboratory experiments of Flexner and Clark. They can, therefore, conceivably accomplish a similar transportation of the virus, as a contamination, in natural infection. Their exclusion from poliomyelitis patients should be zealously carried out. But the main problem relates to the human carrier, active or pas- sive. Where does he harbor the virus, and how is it taken up by the victims? The evidence is growing constantly stronger that the upper respiratory tract, as early pointed out by Flexner and Lewis, is the site both of ingress and of egress of the virus. That the lymphatics of the nasal mucosa are in almost direct con- nection with the subarachnoid space has been clearly demonstrated. Flexner^® has shown in the case of Diplococcus intracellidaris that when monkeys are infected by intraspinal injection of cultures, the diplococcus can be found subsequently both in leukocytes and free in the nasopharynx. This fact and the demonstration of the virus of poliomyelitis in the nasal mucosa of infected monkeys point clearly to the nasopharynx as a path of discharge for agents infect- ing the cerebrospinal space. Successful inoculations of the naso- pharyngeal mucosa of monkeys with poliomyelitis virus have shown, furthermore, that the same path may serve to admit the infecting agent. In addition to the nasopharyngeal mucosa as a source for the dis- tribution of the virus to the outer world, Landsteiner, Levaditi, and Pastia,^'' and Flexner and Clark^* have shown that tonsils from fatal human cases also contain the virus of poliomyelitis. "Flexner, Jour. Am. Med. Assn., 1910, Iv, 1105. "Landsteiner, Levaditi, and Pastia, Sem. med., 1911, xxi, 296. "Flexner and Clark, Jour. Am. Med. Assn., 191 1, Ivii, 1685. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 13 The virus of poliomyelitis is unknown apart from infected human beings and monkeys, and yet it possesses a high degree of resistance. It withstands low degrees of cold and ordinary degrees of heat for long periods of time. When enclosed in albuminous matter, it with- stands drying for several weeks. It can therefore survive both in moist and dry conditions and thus is capable of being carried directly to the upper respiratory mucous membrane as spray produced by coughing and sneezing and even loud speaking of the infected, and as dust. A more detailed discussion of the conditions that affect the virus was given in the historical section. From the evidence at present available, therefore, it is evident that epidemic poliomyelitis is a human-borne, contagious affection, the portal of entry for the virus of which is the upper respiratory tract, in particular, the nasopharyngeal mucous membrane. Other agencies than man play a part in distribution that is distinctly sub- ordinate and inferior. The infection can be carried and implanted both by active and passive carriers; being resistant and having access to external nature with mucous secretions, it can become attached to dead objects, bedding, clothing, etc., and to domestic pets and domestic insects (fly) ; and it can be ground into dust and conceivably be disseminated by wind. Recent experiments of Neu- staedter and Thro'* lend support to this latter hypothesis. These being the probable modes of transmission, preventive measures should be taken accordingly. They are such as are already in use in contagious diseases that have a similar mode of infection; namely, diphtheria and scarlet fever. A further consideration of methods of prevention is given in the section on treatment. Osgood and Lucas^" have shown that the virus is present in the nasal mucosa of recovered monkeys five months after the acute attack of the disease. A simi- larly long period of survival of the virus in the mucous membrane of affected human beings has, however, not been demonstrated. Epidemics rise and fall, and rarely disappear suddenly. The series of cases that form the basis of the present study constitute the instances still arising that owe their initial impulse to the epi- demic wave that appeared in New York in 1909, and has since been slowly disappearing. " Neustaedter and Thro, N. Y.Med. Jour., 1911, xciv, 813. "Osgood and Lucas, Jour. Am. Med. Assn., 191 1, Ivii, 495. Digitized by Microsoft® 14 A Clinical Study of Acute Poliomyelitis. NEUTRALIZATION TEST. As has been emphasized in the discussion of the epidemiology of poUomyelitis, abortive attacks are of common occurrence when the disease is epidemic. These instances of pohomyeHtis are difficult to recognize clinically and a specific biological test would be of great assistance in the diagnosis of such atypical infections. Up to the present time no characteristic reaction has been demonstrated during the acute stage of the disease. Levaditi and Landsteiner, Romer and Joseph, and Flexner and Lewis have shown that the serum of recovered monkeys is able to protect normal animals against fatal doses of the virus. Netter and Levaditi, Flexner and Lewis, and Anderson and Frost have shown that the serum of recovered human cases possesses the same protective property. The last named observers demonstrated this quality in the sera of 66.7 per cent, of a series of abortive instances of poliomyelitis. They also proved that normal human serum has some neutralizing action, but are of the opinion that this action has quantitative limits which clearly differentiate it from the action of the serum of persons who have had poliomyelitis. While such protective bodies do not appear in the serum until about two weeks after the onset of the disease, the fact that the virus is known to survive in the throats of experimental animals for a much longer period of time may make it advisable in extensive epidemics to employ the test in order that the community may be protected from suspected individuals who may act as carriers. Up to the time of the publication of the paper by Anderson and Frost, the reliability of the test was not questioned. These ob- servers show that normal human serum possesses limited power to neutralize the virus of poliomyelitis. During the past year at the Hospital of The Rockefeller Institute, the serum of a number of individuals was tested for its ability to protect monkeys against in- fection with the virus of poliomyelitis. The material consisted of sera from normal persons, from those exposed to infection in the hospital ward, from individuals suspected of having an abortive attack of the disease, and from a certain number of typical cases. The test was performed in the following way : the serum was mixed with a fatal dose of a known active virus, incubated from one Digitized by Microsoft® Francis W. Pealody, George Draper, and A. B. Bochez. 15 :o two hours at 2,7° C. and then allowed to stand for twenty-four lOurs on ice. The injections were made intracerebrally into monkeys {Macacus rhesus). The protocols of the experiments follow. NORMAL SERA. Experiment I. — The serum was obtained from a normal adult, one of the tthysicians in constant attendance on cases of poliomyelitis in the hospital ward. During this time he had presented no signs of illness. One c.c. of the fresh 5erum was mixed with o.i c.c. of virus and was incubated for two hours at 37° C. After standing over night on ice, the mixture was injected intracerebrally into 1 monkey. After seventeen days the animal began to show signs of weakness ind was found dead on the following day. At autopsy the characteristic lesions of poliomyelitis were present in the spinal cord. Experiment II. — In this instance the serum was obtained from a normal adult, a nurse in charge of cases of poliomyelitis in the hospital. She had no paralyses and gave no history of any illness resembling poliomyelitis, nor was she ill at iny time during her service in the poliomyelitis ward. One c.c. of this serum was mixed' with o.i c.c. of virus and neutralization tested in the manner described. The monkey inoculated became ill on the eighth day after injection, [t was somewhat depressed and its movements w^ere slow for several days. On the nineteenth day it developed diarrhea and eight days later it was found dead. A.t no time did the animal show definite paralyses. At autopsy the microscopic lesions were not characteristic. Experiment III. — The serum^ for this experiment was obtained from a girl of eight years of age, a patient in the hospital suflfering from chronic endocarditis. She had no paralyses and gave no history of any illness resembling poUomyelitis. Two tests were made with this serum. The first monkey was inoculated with a mixture of I c.c. of fresh serum and 0.1 c.c. of virus, prepared in the usual way. The animal survived and at no time developed any symptoms. There was no hyperexcitability and no paralysis. A second test was made with this serum, in which I c.c. of serum was mixed with 0.3 c.c. of virus. This animal likewise remained healthy and survived. Experiment IV. — The serum for this experiment "was obtained from one of the doctors in constant attendance on the ward. He gave no previous history of poliomyelitis, but some six weeks previously had a slight illness of about a week's duration, the chief symptoms of which were diarrhea, dizziness, and pain in the neck. There was no muscular weakness. One c.c. of this serum was mixed with 0.1 c.c. of virus and the neutralizing power tested in the usual manner. Seven days after injection, the animal's nutrition was poor; there were no paralyses and no hyperexcitability. On the fortieth day the monkey was still living, when it was again inoculated with i c.c. of serum mixed with 0.3 c.c. of virus. The animal developed diarrhea, became emaciated, and died on the eighteenth day after the second injection, without having developed any paralyses. Experiment V. — The serum of a normal adult, a nurse in attendance on cases of poliomyelitis, was used for this experiment. Some weeks previously she had Digitized by Microsoft® 16 A Clinical Study of Acute Poliomyelitis. a slight illness, lasting three days, the symptoms of which were dizzmess and gastro-intestinal disturbance. There was no muscular weakness and no pain associated with the attack. One c.c. of this serum, was mixed with o.i cc. of virus and after allowing time for neutralization to occur was mjected intra- cerebrally into a monkey. Forty days later the animal was living and had shown no symptoms. At this time another test was made, using i c.c. of serum and 0.3 c.c. of virus. Eleven days later the animal's movements became slow, it grew thin and weak and died on the fourteenth day after the second injection. At autopsy the grey matter of the cord looked somewhat edematous. There were no definite microscopic lesions of poliomyelitis. Experiment K/.— The serum for this experiment was obtained from M. S., two and one half years old, a patient in the hospital suffering from cerebral hemorrhage. Two tests were made with this serum ; in one, i c.c. of serum was mixed with o.i c.c. of virus; and in the other, i c.c. of serum with 0.3 c.c. of virus. The first animal died of poliomyelitis in seven days and the second in eight days. SERA OF SUSPECTED CASES. Experiment F//.— The serum was obtained from Patrick T., aged twenty- three months, a patient in the poliomyelitis ward. At the time of admission to the ward, the patient's sister was suffering from poliomyelitis with paralyses. The patient on admission was drowsy, showed the characteristic irritability on being disturbed, and had slight fever. The spinal fluid showed 94 cells per cmm., practically all of which were of the mononuclear type. Although the mother noticed some weakness in the child when he got up from a sitting posture, the child showed no paralyses while in the hospital. One c.c. of the serum obtained from this patient seven days after the onset of the disease, was mixed with 0.1 c.c. of active virus and injected intracerebrally into a monkey. Nine days later the animal died of typical poliomyelitis. Experiment VIII.— The serum for this test was obtained from Donald P., the brother of a patient who died of poliomyelitis in the hospital ward. He had sihown suspicious symptoms at the time of the other child's illness. The serum was obtained about three weeks after the suspected attack and i c.c. of it was mixed with 0.1 c.c. of virus and injected intracerebrally into a monkey. Ten days later the animal died, having developed a characteristic poliomyelitis. Experiment IX. — The serum used in this test was obtained from H. B., a patient in the hospital. A constant playmate had died of poliomyelitis some two weeks before the patient's admission. The patient, when studied in the ward, had slight fever and showed marked drowsiness. There were no paralyses but slight spasticity on walking and some rigidity of the neck. The maximum cell count in the spinal fluid was 62 cells per cmm., chiefly mononuclear. The globulin • content of the fluid was slightly increased. A monkey, injected intracerebrally with a mixture of 0.1 c.c. of active virus and i c.c. of the patient's serum, ob- tained three weeks after the onset of the illness, showed no signs of poliomyelitis. SERA OF TYPICAL CASES OF POLiaMYELITIS. Experiment X. — For this experiment, serum was obtained from C. T., an adult who had suffered from poliomyelitis thirty years previously. Two tests Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 17 were made with this serum. In one, o.i c.c. of active virus was mixed with i c.c. of serum ; and in the other, 0.3 c.c. of the virus was mixed with i c.c. of serum. Two monkeys were injected with the material in the usual way. Both animals were protected, neither showing any signs of poliomyelitis. Experiment XI. — In this instance the serum was obtained from an individual, E. R., sixteen years of age, who had had poliomyelitis fourteen years pre- viously. One c.c. of serum was mixed with o.i c.c. of active virus and injected into a monkey. Twenty days later the animal developed a paralysis of one leg. The paralysis, however, did not progress and the condition of the monkey returned to normal, with the exception of a residual paralysis. Inasmuch as the dose of virus given has invariably proven fatal in unprotected monkeys, the serum of this patient must be considered as having some protective power. Experiment XII. — The serum for this test was obtained from C. A., a child eleven years old who had had poliomyelitis ten years previously. One c.c. of serum was mixed with 0.1 cc. of active virus and injected into a monkey in the usual way. The animal was protected, showing no symptoms of poliomyelitis at any time. Experiment XIII. — The serum used for this experiment was obtained from M. G., four years old, a patient in the poliomyelitis ward. On admission there was partial paralysis of the external ocular muscles, high fever, and some stiff- ness of the neck. The maximum cell count in the spinal fluid was 320 cells per c.mm. One c.c. of serum obtained thirty days after the onset of the disease was mixed with 0.1 c.c. of active virus and injected intracerebrally into.a monkey. Protection was complete, the animal showing no evidence of poliomyelitis. The above series of tests of the ability of normal, of suspected, and of certain poliomyelitic sera to protect monkeys against in- fection with the virus of poliomyelitis, needs very little comment. Judging from the results obtained, the test cannot be considered to give specific evidence as to whether a given individual has or has not suffered from a previous attack of poliomyelitis. Of the six normal sera tested, but two failed to protect animals against in- fection, whereas four gave complete protection, and three of the latter protected against such large doses of the virus as 0.3 of a cubic centimeter. It is, however, fair to say that in two of the instances in which protection was obtained, the individuals had been con- stantly exposed to infection with the virus of poliomyelitis, and during the time of exposure had suffered from an indefinite illness which might possibly be attributed to an abortive attack of polio- myelitis. In three instances serum was obtained from persons suspected of having poliomyelitis. Of these sera, one protected a monkey against experimental infection and two failed to protect. Two of these individuals were carefully observed in the hospital Digitized by Microsoft® 18 A Clinical Study of Acute Poliomyelitis. and both presented fairly definite clinical evidence of the disease. The serum of one of the latter protected a monkey against infection, and the serum of the one that failed to protect was obtained too early (seven days after the onset of the disease) for the immune bodies to be present in the serum in sufficient concentration. Four sera obtained from individuals vfho had had a characteristic polio- myelitis protected animals against fatal infection in every instance. One serum which was obtained thirty years after the occurrence of the disease, protected against both o.i of a cubic centimeter and 0.3 of a cubic centimeter of active virus. From these results it would seem that in typical instances of poliomyelitis, the serum of the in- fected individual probably always contains, after a certain interval, protective bodies, and that these substances persist for a very long timfe.: In spite of the irregular results obtained with normal sera and the sera of suspected individuals, one cannot as yet rule out the specificity of the test. In the case of apparently normal persons whose serum protects, the possibility must always be borne in mind that he may previously have suffered from an unrecognized, abor- tive attack of the disease. The accurate determination of the pro- tective value of normal serum can probably be made only by a study of sera from very young individuals in whom the possibility of pre- vious infection can certainly be excluded. PATHOLOGY. The earliest pathological studies in poliomyelitis were made on chronic cases of the disease, and the lesions described were the atrophic scars found in the anterior horns of the cord. With the development of a better clinical knowledge of the acute stage of the disease, a new pathology arose which laid especial stress on the earliest morphological changes in the cord, and explained their rela- tion to the development of the chronic forms. The work of many investigators, notably Harbitz and Scheel," Wickma.n,^^ and Strauss,23 has produced an accurate picture of the anatomical lesions " Harbitz. and Scheel, loc. cit. ^ Wickman, Die. akute Poliomyelitis, loc cit., p. 13. "" Strauss, The Pathology of Acute Poliomyelitis, Report on the New York Epidemic of 1907 of the Collective Investigation Committee, New York, 1910. Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 19 occurring in the brain and spinal cord. The attention of observers has hitherto been almost wholly centered on the lesions of the central nervous system, and in consideration of the fact that the most strik- ing disturbances, both pathological and clinical, are associated with the nervous system, this is not remarkable. In view, however, of; the very definite and constant changes which are found at autopsy in other viscera, it is rather strange that they should have been almost wholly disregarded, and that so little emphasis should have been put on the fact that acute poliomyelitis is essentially a general infection. Rissler,** Strauss, Harbitz and Scheel, and 'yVickman have all noted the presence of lesions outside the nervous system, but have passed them by as having little bearing on the disease. As a: matter of fact, the recognition of acute poliomyelitis as a general infection has an important bearing both in explaining the clinical course of the disease and as affecting any possible means of treat- ing it. Inasmuch as the lesions of the central nervous system are of chief importance, they may be considered first. At autopsy the meninges are usually found to be somewhat edematous and injected. There is little increase of cerebrospinal fluid. The brain and cord, on section, have a moist, translucent, edematous appearance, and the gray matter of the cord is often swollen so that it projects above the level of the white matter. It is darker than normally in color and is typi- cally of a grayish pink hue. Not infrequently minute hemorrhages can be distinguished in the gray or white matter. The exact path by which the virus enters the body is at present not definitely known, but there is clinical and experimental evidence which makes it seem probable that infection frequently gains access from the upper respiratory tract. It has been shown both anatomi- cally and experimentally (Flexner^**) that the upper nasal cavities are in direct communication with the meninges by means of the lymphatics which pass outward with the filaments of the olfactory nerve. The view that the virus may enter the body by means of those lymphatics and thus exert its first effect upon the meninges is °*Rissler, Zur Kenntniss der Veranderungen des Nervensystems bei Polio- myelitis anterior acuta, Nord. med. Ark., 1888, xx, i. *Flexner, Jour. Am. Med. Assn., loc. cit. Digitized by Microsoft® 20 A Clinical Study of Acute Poliomyelitis. strengthened by the anatomical findings. The earliest change which has been described in the nervous system is hyperemia and the col- lection of numbers of small mononuclear cells, probably lympho- cytes, in the perivascular lymph spaces of the blood-vessels of the leptomeninges. These lymphatic spaces surrounding the vessels are anatomically processes of the arachnoid spaces, and the lymph in them is in communication with the cerebrospinal fluid. This first change, then, is an acute interstitial meningitis, which is not asso- ciated with fibrin formation or with exudate on the surface of the meninges. It is usually most marked on the anterior surface of the spinal cord, and especially in the anterior fissure, from which the larger vessels enter the cord (figure i) ; but smaller collections of cells are often found along the meningeal vessels which are situated •over the lateral and posterior aspects of the cord. The blood supply of the cord is derived from the vessels of the meninges, and with the advance of the pathological process, this perivascular infiltration follows along the vessels as they enter the cord from the meninges. Thus the earliest change that is found in the cord itself, both in human beings and in the experimentally produced disease, is hyper- emia and the collection of small round cells in the lymph spaces sur- rounding the vessels. This cellular exudate forms a sheath ap- parently completely surrounding the vessels for long stretches (figure 2), and in many places the cells are so numerous that they form thick collars which seem to press on the lumen, and thus exert a mechanical effect in obstructing the circulation. While the cellular exudate is in the outer part of the vessel wall, it is probable that there is often some effect, either toxic or mechanical, on the intimal lining of the vessels, for hemorrhages (figure 3), minute or extensive, are frequent findings, and one of the prominent features of most cases is the extensive edema. These three factors, cellular exudate, hemorrhages, and edema, all ai them dependent on vascular changes, may perhaps be regarded as the primary reaction of the nervous system to the virus of poliomyelitis. The effects produced on the nerve cells themselves are probably either dependent on these vascular disturbances or they may be due •to a direct action of the virus. This superior importance of the vascular system in determining the nervous lesions has for a Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 21 ig time explained the fact that the cervical and lumbar enlarge- :nts of the cord are most affected, and that the anterior horns of e gray matter are more involved than the posterior horns or the lite matter. These are, of course, the regions of the spinal cord which the blood supply is most abundant. Moreover, the fre- lency with which lesions are asymmetrical probably depends on e irregularity with which the vessels supplying the cord are given f at different levels. It has been suggested that the process by eans of which the vascular lesions affect the nerve cells may be sentially a mechanical one. It is quite impossible to exclude the ct that the virus may exert some directly toxic action on these lis, but in many ways, the clinical and anatomical pictures are adily explained by the presence of the circulatory disturbance and the exudate. On such an hypothesis the damaging effects can ; assumed to result in part from the direct pressure on the nerve Us of hemorrhages, edema, and exudate. There is also the addi- )nal factor of anemia following the constriction of the blood ;ssels by the same mechanism. On account of this pressure and lemia, the nerve cells degenerate. If the hemorrhage and exudate e absorbed soon enough, the cells may recover their function. If, 1 the other hand, the anemia and pressure have been prolonged or xessive, the nerve cells go on to complete necrosis. Histological :amination shows nerve cells in all stages of degeneration, from ose with the slightest changes in their protoplasm to others of fiich only a granular detritus remains. A most striking picture formed by the entrance of polymorphonuclear neurophages into e necrotic nerve cells (figure 4), A single nerve cell may be in- ided by a dozen of these phagocytes, and by means of them ne- otic material is completely disposed of. In more severe lesions, le sees the hyperemia, the perivascular infiltration, hemorrhages, [ema, and a diffuse cellular infiltration throughout the gray and hite matter, but nerve cells may be completely absent from the cture. These changes, most prominent in the anterior horns of e gray matter, are not sharply circumscribed, but are scattered ore or less diffusely through both the gray and white matter of e cord (figures 5, 6, and 7). The same sequence of changes, vascular disturbance, and subse- Digitized by Microsoft® 22 A Clinical Study of Acute Poliomyelitis. quent degeneration of the nervous elements, is found to a less degree in the brain, medulla (figure 8), and pons. Hyperemia and a mod- erate amount of cellular infiltration may be found in association with the vessels of the cerebrum and cerebellum, but lesions exten- sive enough to produce motor symptoms are exceedingly rare. The medulla and pons show some slight degree of involvement in most cases, and one frequently finds in them a marked cellular exudate and many hemorrhages. It is noteworthy, however, that it is often extremely difficult to reconcile the clinical symptoms, which are referable to pontine lesions, with the actual autopsy findings. Cases which have shown bulbar paralyses in life may fail to show ade- quate anatomical lesions to account for them, and other cases which have given clinical evidence of spinal involvement only may show changes through the pons and medulla. Of practically constant occurrence are the lesions in the posterior root ganglia. The histological changes are similar to those that take place in the cord itself (figures 9 and 10). There is an infiltra- tion of small round cells in the lymphatic spaces surrounding the vessels which enter the ganglia from the meninges. This has been shown experimentally to be the first step in the process. Then fol- lows a more general, diffuse exudation of cells, degeneration and necrosis of the nerve cells, and finally the entrance of polymorpho- nuclear leucocytes into the necrotic cells and removal of the disin- tegrating cells by neurophages (figure 11). The suggestion has been made th^ these lesions in the sensory ganglia may in part account for the pain which is such a constant feature of the acute stage of the disease. Another element in the production of pain is the cellular infiltration which is found along the nerve roots. The changes which are found in other organs in acute poliomye- litis are less striking than those in the nervous system, but they have been, in our experience, practically as constant. In all of the eleven acute cases which we have been able to examine, there has been more or less extensive involvement of the lymphoid tissue and of parenchymatous organs. The lymphoid tissue throughout the body appears to react to the virus. The Peyer's patches of the intestine and the mesenteric lymph glands show perhaps the most marked acute swelling. The mucosa over the Peyer's patches is. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 23 owever, unaffected. There is also definite, and sometimes pro- ounced enlargement of the substernal, bronchial, cervical, axillary, nd inguinal lymph glands and of the tonsils. The spleen is fre- uently somewhat enlarged, and on section the Malpighian cor- uscles stand up in raised, pale, obviously translucent nodules. The lymus shows changes identical with those in the lymphoid tissue Isewhere. On histological examination, one is struck by the resem- lance of the lesions found to those described by Mallory*® in >fphoid fever. The reaction is, in general, the same throughout the rmphoid tissue, regardless of its location. On histological exami- ation some of the lymphoid nodules may present a normal appear- nce, but the majority consist of a zone of lymphocytes surrounding more or less sharply circumscribed pale center (figure 12). High lagnification shows the center of the lobule to consist chiefly of irge endothelial cells with oval vesicular nuclei. These cells are imilar to the cells lining the lymph sinuses, but most of them are irger, more swollen, and take the stain very lightly. Sometimes ie nuclei look like pale shadows, and the outline of the protoplasm 5 so faint that it can scarcely be distinguished. Where they are losely packed, the individual cells appear to be fused together to orm compact masses. The better preserved of these cells are larkedly phagocytic and frequently contain many particles of ecrotic cells. These cell inclusions are surrounded by a lightly tained halo and are apparently situated in vacuoles in the proto- lasm. Scattered throughout the center of the nodule are many roken down cells and granular fragments of necrotic nuclei. The ells which are going to pieces are for the most part lymphocytes, ut the endothelial cells also seem to swell up and finally disin- ;grate. In areas with extensive necrosis there is often an invasion y polymorphonuclear leucocytes. In the lymph sinuses there are also large numbers of the same hagocytic endothelial cells. Many of them are of great size and Dntain necrotic fragments of nuclei, whole lymphocytes, or num- ers of red blood corpuscles. In the lymph sinuses, there is exten- ive proliferation of the endothelial cells, as is evidenced by the requency with which mitotic figures are found. Numbers of ne- ""Mallory, Jour. Exper. Med., 1898, iii, 611. Digitized by Microsoft® 24 A Clinical Study of Acute Poliomyelitis. erotic cells are met with in the lymph sinuses, but, in general, necrosis is a more prominent feature in the centers of the lymphatic nodules, and proliferation in the lymph sinuses. Among the parenchymatous organs, "cloudy swelling," such as has been frequently described, is usually met with. In the liver, however, there are other more striking changes, and these again resemble in character those that have been described by Mallory and others in typhoid fever. They are for the most part sharply circum- scribed areas, ranging in size from lesions which consist of one or two cells to others which include nearly one eighth of a liver lobule, in which degeneration of liver cells and infiltration of lymphoid cells and polymorphonuclear cells have taken place (figure 13). The number of these necroses is very variable. They may be rather difficult to find, or there may be many of them in a single low power field. The lesions are apparently closely associated with the blood vessels, and while chiefly with the portal vein, they are also asso- ciated with central or sublobular vessels. The section is, however, sometimes cut so that the relation to the blood-vessels is not directly evident. The lesions are round or oval in cross section, but there may be long finger-like projections, extending out from the main area, and involving one or two columns of liver cells. It is striking that the liver cells directly adjacent to the infiltrated areas are usu- ally completely spared, but occasionally one finds that some of them show a homogeneous quality of the protoplasm, and an exaggerated affinity for eosin, which suggest a beginning involvement through a peripheral spread of the lesion. The character of the lesion varies, of course, with its size and age, but in general it is very constant. In the earlier lesions one finds one or two disintegrating liver cells, with homogeneous, hyaline, pink-staining protoplasm, and occasionally with irregular, distorted nuclei. In the older lesions, even more apparent than the necrotic liver cells is the evidence of an early and rapid proliferation. Scattered through practically all the lesions are small groups of liver cell nuclei, frequently a nest of three or four nuclei surrounded by infiltrated tissue, or several nuclei apparently beginning to pro- liferate within a degenerated liver cell body. The protoplasin around these dividing nuclei may appear as a faint pink halo, or it may be Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 26 quite impossible to make out any protoplasm at all. In older lesions, the protoplasm is better defined and the cells have frequently arranged themselves circularly, in acini, or in double columns. This arrangement of cells simulates that in normal bile ducts, but it is found in association with nearly all the lesions, irrespective of their position in the lobule, although most frequently adjacent to the portal spaces. According to the position of the infiltrative lesion, much or little fibrillated tissue appears among the degenerating and infiltrating cells. The greater amount of fibrillated tissue occurs in and adjacent to the portal spaces, where all the lesions of an early cirrhosis may be displayed. That this condition is of the nature of a beginning cirrhosis is further indicated by the microscopic de- pressions of the capsule of the organ, where the lesions extend to- ward and reach that structure. However, the process probably is not permanent, since it is so young and cellular that it can readily undergo retrogression ; while the infiltrated nodules elsewhere in the lobules are surely easily subject to restoration. One case has indeed come to autopsy, the child dying of a laryngeal diphtheria two months after the onset of poliomyelitic paralysis affecting both legs. In the liver of this case were remains of the portal infiltrative lesions described and, in addition, younger necrotic and infiltrated lesions among the columns of liver cells. The former probably had been greater and were diminishing; it is uncertain whether the latter were residues of the poliomyelitic infection or the result of the recent diphtheritic process. That these changes in the lymphoid tissues and in the liver are, in fact, a part of the reaction of the body to the virus of poliomyelitis, would seem to be made certain by the fact that exactly similar lesions may be found in the organs of monkeys which have been experimentally infected with the disease (Flexner*''). The demonstration of such a widespread reaction to the virus is wholly in line with recent clinical and epidemiological advances which tend to recognize acute poliomyelitis as a general infection. The disease must be regarded as a generalized process which affects parenchymatous organs, lymphoid tissue, and more especially the nervous system. It is possible that two distinct effects of the disease "Flexner, Folio serolog., 1911, vii, iioi. Digitized by Microsoft® 26 A Clinical Study of Acute Poliomyelitis. on the organism should be differentiated. On the one hand is the general toxemic process which affects organs throughout the body, but which apparently acts mildly. On the other hand is the local process in the spinal cord, producing death by destruction of the nerve cells controlling respiration. The anatomical findings which point to an action of the virus of poliomyelitis on the lymphoid ■ tissue throughout the body may well be correlated with the results obtained by the inoculation of emulsions of lymphoid organs into monkeys. Not long after the disease was first transferred to monkeys by the intracerebral inoculation of filtrates of the spinal cord, the virus was proved, in the same manner, to be present in a mesenteric lymph gland. Since then similar positive results have been obtained with still other lymphatic glands in the monkey, and with emulsions of the tonsils in man and the monkey. These observations are not, however, of the same significance and importance. What they tend to indicate is that the living virus may come to rest for a time in organs outside the central nervous system, to which it is conveyed by the blood. It does not establish the fact that the visceral lesions outside the nervous system are caused directly by the virus, rather than by some secondary toxic substance produced in the course of its proliferation. Since the only means at present available to demonstrate the presence of the virus is the in- oculation of monkeys, the tests made are too few to determine how widespread in the organs the virus really is. It is established that it is present in the central nervous system, even when it cannot be demonstrated in the viscera generally. But the finding of the virus in the tonsils and nasal mucosa with as great constancy as in the nervous system indicates that these organs play a part in the con- veyance of the virus into and away from the central nervous system. The virus is regularly present in them in fatal and doubtless in non- fatal cases of poliomyelitis in children, and it has been demonstrated in the nasal mucosa, the tonsils, and even in the nasal mucous mem- brane in infected monkeys; it finds its way into the nasal mucous membrane, even when injected into the peritoneal cavity. The evi- dence, therefore, is strong that, as was first pointed out by Flexner, the upper respiratory mucous membrane provides for both the ingress and egress of the virus of the disease, through which infec- Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 27 on is produced and the renewal of the cause of the disease main- lined. SYMPTOMATOLOGY. CLINICAL CLASSIFICATION OF CASES. The study of any disease is simpHfied if the various clinical forms 1 which it may appear can be grouped together into a few definite ypes. While no two cases of any disease are ever exactly similar, ne probably finds variety of gross clinical manifestation most strik- rigly illustrated in the diseases of the nervous system, and a patho- Dgical process which may extend more or less continuously through irain, medulla, pons, spinal cord, and spinal ganglia, or which may le localized in any part of this system may produce signs and ymptoms of very diverse character. Such are the possibilities that ire present in poliomyelitis, and it is no wonder that the clinical las'sification of cases has been the subject of much discussion. The nost generally accepted system has been that of Wickman, who ecognizes eight forms: (i) the spinal, poliomyelitic form, (2) the ;ases simulating Landry's paralysis, (3) the bulbar or pontine form, [4) the encephalitic form, (5) the ataxic form, (6), the neuritic form, (7) the meningeal form, and (8) the abortive cases. While ;uch a classification certainly covers all possible cases and makes it :asy to place most cases in their appropriate groups, it does not ap- pear to us to be wholly satisfactory. It is based neither on patho- ogical anatomy, nor on clinical symptomatology, but on a mixture )f the two. The spinal, the bulbar, and the encephalitic forms are inatomical forms ; the neuritic, the meningeal, and the ataxic forms ire essentially symptomatic forms. A more satisfactory classifica- ;ion would be either anatomical or clinical. Such a classification ivould simplify a confusion arising from the use of two systems, for it is impossible to draw any hard and fast line between some of ;he groups. Thus most neuritic forms are essentially of the spinal :ype, and most meningeal cases are either spinal or bulbar. The itaxic form Zappert regards as based on a single, not especially prominent symptom, rather than on an anatomical foundation. The :ases simulating Landry's paralysis are in the main instances of the spinal type in which the process advances, usually to end in death Digitized by Microsoft® 28 A Clinical Study of Acute Poliomyelitis. from involvement of the respiratory muscles. Cases that are classed among the meningeal or neuritic forms are so classed be- cause they show some of the clinical manifestations of meningitis or of neuritis, rather than because they have a pathology which is essentially different from other bulbar or spinal cases. These types of the disease are, in fact, not true types at all. They merely repre- sent some of the variations in symptomatology which may be found more or less developed in association with either the abortive, the bulbar, the spinal, or the cerebral types of the disease, and their enumeration as definite forms is complicating and at times confus- ing. As a result of this duplicating and overlapping of sub- divisions, the picture of the disease, as a whole, is made much more complicated and obscure than is necessary. More simple and, at the same time, more practical is the classifica- tion proposed by Miiller. Adopting, as far as possible, an ana- tomical basis, he proposes the four following classes : ( i ) the spinal form, (2) the bulbar form, (3) the cerebral form, and (4) the abortive cases. In any system of classification, the abortive cases must, of course, form a distinct type. In considering the cases, however, which result in paralysis, one would seem to get a clearer outline of the disease process, if the cases are looked at from the point of view of pathological physiology and divided into two main groups : ( I ) those cases in which the upper motor neurone is primarily affected, and (2) the larger group of cases in which the lower motor neurone is involved. The first group is the cerebral form of Miiller, and the second group is composed of his spinal and bulbar forms. The two latter forms it is wiser to consider together, as in both the lesion is essentially the same, a lower motor neurone lesion involving, on the one hand, the nuclei of the pons or medulla and, on the other hand, the anterior horn cells, the result being in either instance a flaccid paralysis with subsequent atrophy. The two types which are thus based on similar pathological lesions are also inseparable clinically, for a somewhat larger number of cases occurs with cranial nerve involvement, in association with spinal lesions, than occurs with cranial nerve involvement alone. The third group of cases in Miiller's classification is the cerebral type, the same group to which Wickman gives the name encephalitic. This Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 29 is a fairly definite pathological entity, at least in so far as the most prominent lesion apparently involves the upper motor neurone. While the bulbospinal type is characterized by flaccid paralyses, this •cerebral type is characterized by spastic paralyses or by other evi- ■dence of a lesion above the lower neurone. The exact location of the pathological processes in these cases is not wholly clear, but it seems probable that the upper neurone may be attacked in either or l)Oth of two places. Some few cases are probably due to lesions in the cortex with involvement of much larger areas than are com- monly found. Other cases, the majority, seem to depend on in- volvement of the pyramidal tracts, either high up or in the cord. 'That this class of case, originally described by Striimpell as polioen- •cephalitis acuta is very uncommon, but that it is in reality a form ■of infantile paralysis, has been made quite certain by epidemiological studies which show the spastic type occurring in the same epidemic ^nd in the same house with the flaccid types, by the occasional -occurrence of both spastic and flaccid paralyses in the same patient, as well as by the pathological studies of Harbitz and Scheel. It would seem, then, that the best appreciation of acute polio- myelitis, from the clinical point of view, is obtained if one recognizes three groups of cases. The first group consists of the abortive •cases, cases of infection which never become paralyzed. The second or cerebral group contains the rare cases in which involvement of the upper motor neurone with resulting spastic paralysis is the chief •characteristic. The third or bulbospinal group is much larger and ■comprises all cases with lesions in the lower motor neurone and -flaccid paralyses. Such a classification is, of course, open to the objection that many •cases are not purely of one type, either anatomically or clinically. Thus most bulbospinal cases show some pathological foci in the brain, and cerebral cases may show lesions extending into the cord (Harbitz and Scheel). Then from the clinical point of view a •certain number of bulbospinal cases develop symptoms as, for in- stance, ataxia, which may well depend on an upper motor neurone lesion, either in the brain or cerebellum, in the pyramidal tracts, or in Clarke's columns. When one recognizes how diffusely the patho- logical process extends through the whole central nervous system. Digitized by Microsoft® 30 A Clinical Study of Acute Poliomyelitis. it becomes evident that it is impossible to make any hard and fast classification which shall be strictly applicable to all cases. The best one can do is to attempt to reconcile the chief clinical symptoms with the predominant anatomical lesion. In the following sections, we shall consider the symptomatology and course of each of these types in detail. PREDISPOSING CAUSES. Acute poliomyelitis is a disease which shows very definite sea- sonal variations in its incidence. The records of epidemics in many countries show that it occurs during the summer and reaches its maximum in the late summer and early autumn. In the Swedish epidemic of 1905, 86 per cent, of the cases had their onset between July and October, and 35 per cent, during August. The New York epidemic of 1907 showed a very similar curve, reaching its maxi- mum, however, . in September. Other epidemics show some slight variations in duration and in the period at which the highest point is reached, but that the disease is distinctly one of summer and fall has been generally accepted. There are a few well substantiated epidemics which prove that poliomyelitis may also occur during cold weather. Wickman cites one epidemic in the north of Sweden, last- ing through the winter, and reaching its maximum in April and May. He also reports three closely related epidemics, occurring in neighboring sections of the country, the first (eighteen cases) lasted from June to October, the second (twenty-seven cases), from July to December, and the third (sixty-two cases), from the end of September to February, with its maximum in November and De- cember. These winter epidemics are of interest in relation to attempts that are being made to account for the spread of the disease by some intermediary insect host. Stress has been laid on the fre- quent occurrence of epidemics of poliomyelitis in unusually hot, dry years, but this relationship is certainly far from constant. It has been generally noticed that acute poliomyelitis is a disease of open country, rather than of cities. Among our own cases, a relatively larger number of children came from the suburbs and surrounding country than from the densely populated tenement district in which the hospital stands. Moreover, a considerable Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. 31 proportion came from families which are in comparatively well- to-do circumstances and in which the children enjoy every comfort and care. Pneumonia, measles, and other acute diseases are often mentioned as predisposing causes of poliomyelitis, but in our experi- ence the absence of any history of previous illness has been much more noticeable. In general, they had been perfectly healthy children. Childhood is essentially the age which is most susceptible to polio- myelitis, but that adults are by no rheans immune is shown by Wick- man's statistics.' More than one fifth of ;his cases were persons over fifteen years old. He mentions one case in a man of forty-six years, and instances' of the disease occurring in even older persons are on record. In the New York epidemic of 1967, the youngest case was two weeks old. Three cases seen by us were three months old, and fifteen cases were between six and twelve months. As in the 1907 epidemic in New York, the majority of our cases were between the ages of one and three years. The figures obtained by Mtiller agree rather remarkably with ours in respect to age incidence. Of his cases 96 per cent., and of ours 97 per cent, were in the first decade, while 90 per cent, of his, and 89 per cent, of ours were below the age of five. Perhaps the age most liable to infection is the latter half of the second year. Both sexes are almost equally susceptible to the disease, the number of males being slightly greater than the number of females. TABLE OF AGE INCIDENCE. ■ Months. Years. Under 6 I ^ X X t^ ^ I I M 01 I I ■I Over 25 Total. Rockefeller In- stitute Hos- pital, 191 I. . 3 15 62 221 29 180 ■ 18 13 6 28 4 18 II 2 II I 7 3 14 S ■ I I IS7 New York Epidemic, 1907 62 106 63 2 729 Wickman, Sweden, 1905- 183 214 179 229 220 1,025. Digitized by Microsoft® 32 A Clinical Study of Acute Poliomyelitis. THE PRODROMAL PERIOD. In most typical cases of infantile paralysis, the course of the disease is fairly constant. A period of incubation is followed first by a period of prodromal symptoms, then by an acute stage with paralysis, and finally by a stage of retrogression. The duration of the incubation period is variable. In the experimental disease in monkeys, Flexner has found that the time elapsing between inocula- tion and the onset of paralysis is from three or four days to thirty- three days, the average being eight or nine days. Prodromal symp- toms are of short duration in the monkey, rarely lasting over twenty- four hours. With a virus that has been passed through several generations of monkeys, and has thus become adapted to its new host, the period- of incubation is much more constant than it is on the first transfer from man. Such a fixed virus causes paralysis with great regularity in seven or eight days. In the disease in man it is obviously much more difficult to determine the exact length of the incubation period. Thus, even when two cases appear in one family, it is often impossible to be certain at what time the second case became infected by the first, or even whether both were not infected at the same time from a common source. Wickman considers the incubation period as being from one to four days, his opinion being based on the interval between the dates of onset of the disease in two persons of the same family. Our own observations of families in which two cases have occurred would lead us to a nearly similar conclusion, but we believe that these are in all probability simultaneous infections from a common source. At any rate, previous contact had been so intimate that infection might have taken place at any time during the incubation period of the first case. In one family at least, two children became para- lyzed on the same day. Miiller has seen six instances in which the length of the incubation period could be determined more accurately, and he concluded that it varies between five and ten days. The average incubation period was about a week, thus practically the same as is found in the experimentally produced disease. Following the incubation period and preceding the onset of paralysis, there is, in the vast majority of cases, a period marked by prodromal symptoms. These symptoms are at times of such Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 33 ild and fleeting nature that they may be entirely overlooked, but ;pt in the case of small babies, and with unusually unintelligent ;nts, careful history taking will almost always bring out evidence ome prodromata. There is, however, a small number of cases /hich the acute stage with paralysis really seems to be the first vard manifestation of the disease. We have seen several cases irring in intelligent families in which, in spite of careful ques- ing, it was impossible to obtain evidence of prodromal symptoms. ; usual history in this rather exceptional type of onset is that child goes to bed perfectly well and wakes up paralyzed. These -esent but a very small fraction of the total number of cases; others give a definite history of a prodromal stage. The dromal period, which, until recently, received little attention at hands of clinicians, has, in the light of our present knowledge epidemiology and of our hopes for a therapeutic control of the ;ase, assumed an unexpected prominence. It is during the dromal period that one must isolate and quarantine, if such isures are expected to be efficacious, and it is only in the prodro- . period, before an extensive destruction of nerve cells takes ;e, that one can ever hope to make treatment efficient. This is, refore, the most important stage in the course of the disease, for its recognition depends the possibility of controlling the infection. The duration of the prodromal symptoms is variable. In our ies of cases they lasted, in most instances, from one to seven s, with one to three days as an average. The usual history is t the symptoms increase progressively in severity through the dromal period, but occasionally, after being sick for two or three 'S, there is a distinct cessation of symptoms and the child appar- ly recovers. One or two days later, however, and perhaps with- further warning, the child becomes paralyzed (case i, page 122). The severity of the prodromal symptoms, also, varies greatly from e to case. While in one child they are so mild and transient that y are quite disregarded, in another they may be alarming. In a isiderable percentage of our cases the children were sick enough ■ing the prodromal period to make the mothers feel that a doctor uld be sent for. It is a generally accepted fact that the severity the prodromata bear no relation to the extent of the ensuing alysis or to the subsequent course of the disease. Digitized by Microsoft® 34 A Clinical Study of Acute Poliomyelitis. The prodromal symptoms are, on the whole, of a general nature. A few are more specific in character and shed some light on the nature of the disease. For the most part they are such as may appear at the onset of almost any acute infection or, indeed, such as occur in children with very little recognizable cause. While indi- vidual cases show considerable differences, there are certain groups of symptoms which are present in the majority of all cases. Other types of symptoms have been shown to have a tendency to vary from epidemic to epidemic. Thus in the epidemic which occurred in Hesse-Nassau and was reported by Miiller, the majority of the cases had prodromal symptoms referable to the respiratory tract. In the neighboring province of Westphalia, during the same epidemic, Krause^® found a preponderance of cases with gastro- intestinal symptoms. Two thirds of his cases had a marked diar- rhea. During the New York epidemic of 1907, intestinal symptoms were not marked, but gastric disturbances were common. - Probably the most constant feature of the prodromal period is fever. In most cases this is noted among the earliest symptoms, in fact the usual story is that the patient was perfectly well in the morning, but towards evening became feverish. Sometimes fever was apparently not noticed until the second or third day after the child became sick, but this may be due to the fact that a history of the presence or absence of fever is usually based on the appearance of the child and the temperature of the skin, rather than on actual temperature determinations with the thermometer. However, in a number of cases, actual measurements showed that a temperature of 103° F. or higher is of frequent occurrence. Onset with chill is comparatively rare. The febrile reaction generally lasts through the prodromal period, with slight morning remissions, and the tem- perature comes down to normal a few days after paralysis sets in. Occasionally the fever remits earlier, especially in those cases with a distinct interval, in which the child is without symptoms, between the prodromata and the acute stage. Miiller has laid special stress on profuse sweating, which he designates as one of the cardinal symptoms of the early stage of the disease. It was present in 75 per cent, of his cases. A definite '" Krause, Deutsch. med. Wchnschr., 1909, xxxv, 1822. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 35 lanation of the mechanism of its production he is unable to give, he suggests that a pathological involvement of spinal sweat ters may play a part. The question of sweating was carefully le into in our histories, but in only 25 per cent, of the cases I it been noticed at all. The number of cases with profuse, nching sweats was very small. One naturally expects to find mating a rather common accompaniment of fever, especially in Idren, and the comparatively slight transient sweats met with in St of our cases were no more than could be explained by the irile reaction, and by the warm summer weather. On the whole, mating was not a prominent symptom in this series of cases. The V cases in which sweating persisted after the temperature became •mal will be discussed in the following section. \ssociated with fever and perhaps dependent on it, is drowsiness, ich was a very noticeable symptom in many cases. The children : apathetic and want to sleep most of the time. This drowsiness netimes lasts only a day or two and then disappears, but often it reases and runs into a mildly stuporous condition with the onset the acute stage. With flushed face and dulled, apathetic sen- ium, the child may have a definitely typhoidal appearance. Fre- ;ntly, the degree of apathy is out of all proportion to the height the temperature. On being awakened, the patient is usually irri- )le. He cries and wants to be let alone to doze off again. Not in- iquently drowsiness is less prominent, and irritability with a nerv- 3, excited, complaining disposition replaces it. One baby, whom watched in the prodromal period, was wide-eyed, alert, nervous, servant of all that went on around her, breathing rapidly, and nng. when anyone approached her or attempted to touch her. is irritability is closely connected with what Miiller considers as ; of the three cardinal symptoms of the prodromal period, hyper- hesia. This symptom, which was present in three quarters of the ies in the Hesse-Nassau epidemic, was also very constantly seen our cases. Muller mentions a hyperesthesia of the skin of which : found no instance in the preparalytic stage, but pain on passive o fa % ta \ to o [a o '8 to to 8 to So to °o 1 I 2 I 2 1 I 3 I 2 2 4 I 2 2 1 1 1 S 2 3 s 1 6 I I 3 2 7 1 2 2 3 8 I 2 I 9 I 3 10 1 I TEMPERATURE TABLE NO. 2. 2d Day. 3d-6th Days (Inclusive). 7tb-ioth Days (Inclusive). Temperature. Number of cases. Temperature. Number of cases Temperature. Number of cases. 98° F. 100.6° F. 102.6° F. 103.8° F. 1 1 2 I 98° F. 99° F. 100° F. 101° F. 102° F. 103° F. 104° F. 4 9 I 8 7 I I 97° F. 98° F. 99° F. 100° F. 103.3° F. 105° F. 1 8 6 2 I I Total number of cases = 54. It is obvious that after the fourth day there are only eleven cases with temperature over 99° F., whereas there are twenty-five cases with temperature of 99° F. or less. Before and including the fourth day, fifteen cases had temperatures above 99° F., and only three 99° F. or less. Consequently, since most of the patients have come under our observation after the acute stage has begun, the charts in the hospital have shown only the end of the temperature curve. Many of the cases have had continued low temperature, varying from just above normal to 99° F. or 99.5° F. for several weeks. Possibly there is a slight relationship, at least in point of time, be- tween the onset of paralysis and the fall of temperature. This is not especially definite, nor does there seem to be any particular reason Digitized by Microsoft® 50 A Clinical Study of Acute Poliomyelitis. why it should be. A somewhat remarkable feature of the tempera- ture in many cases is the fact that its presence is shown only by the thermometer. The patients do not seem feverish. The typical end of the temperature curve is a sharp lysis, lasting usually twelve to twenty-four hours. Some cases have a much slower fall, and the temperature abates very gradually through two, three, or more days. In these cases it occasionally runs on for two or three weeks at just above normal. All the temperatures were taken by rectum, however, so that a curve in the smaller children continuing between 99°, 99.5", or 100° F. is hardly to be considered an abnormal elevation. //. Cases without Prodromata in Which Paralysis is the First Symptom. — A glance at text-figure i will show that in the seventy- two cases analyzed, only 4^ per cent, began with paralysis. In these instances the children have been brought to us on the first or second day of the disease. Usually they have the aspect of patients who have begun in the ordinary way, for in almost every case the child has been found in a drowsy, irritable state, and sometimes has vomited within twenty-four or forty-eight hours after the appear- ance of the muscular weakness. In one instance, the typical tender- ness on spinal flexion developed after a day or two and persisted rather longer than usual. In general, therefore, these cases do not differ essentially from the more common type of the disease. They are a most significant group, however, from the therapeutic point of view. With them there has been no warning, and checking a pos- sible advance of paralysis is the only hope (case 7, page 133). ///. Cases with Remission of Symptoms and Delayed Paralysis. — In the prodromal period described above, the occurrence of remis- sion in the symptoms was discussed. A somewhat similar phe- nomenon sometimes appears in the acute stage of the disease, but very rarely. Thus a child will become less drowsy rather suddenly and, after seeming to be better for a day or two, again become irri- table and sicker than before (case 8, page 134). In one case in which the spinal fluid had shown marked improvement, and the clinical symptoms were distinctly better, there was a sudden change late in the disease. The globulin content of the spinal fluid rose to double plus and at the same time the patient became highly nervous, Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 51 trembled, and had almost a spastic condition of the muscles of the arms. A Babinski reaction was also present. Subsequently the case improved again and left the hospital with only a slight residual paralysis. IV. Cases with Deep Stupor. — An important clinical type of the disease, about which a good deal of confusion in nomenclature exists, still remains to be considered. The term "cerebral" or " encephalitic " was applied by Striimpell, Wickman, Miiller, and others to describe those few rare cases which have had spastic paralyses, dependent upon upper motor neurone lesions. Recently, however, there has crept into the literature a confusing use of the words cerebral and encephalitic. They have been applied rather loosely to cases of poliomyelitis which have had marked disturbance of the sensor ium. In view of the accompanying paralysis, these cases properly belong to the bulbospinal group. The only clinical evidence to indicate that cases of the type about to be described are poliomyelitis is the paralysis, which is usually of the flaccid or lower motor neurone variety. Ultimately it may be proper to consider that profound disturbances of the sensorium in this dis- ease are due to lesions of the silent brain areas, but we have no anatomical evidence as yet for this assumption. Consequently, if an anatomical classification is accepted for the disease as a whole, these cases must be grouped primarily according to the anatomical lesion indicated by their paralyses. Usually this is bulbar, but it may also be spinal. Profound stupor, however, is such a striking feature that it must be recognized in any system of classification; but in relation to a primarily anatomical grouping, it can merely be placed as the sub-heading of a clinical variety. Therefore it is simplest to consider these as cases of bulbospinal poliomyelitis with profound stupor. In its manner of onset, this clinical sub-group of the disease does not differ materially from the usual type. If there is any dififer- ence, it is that drowsiness preponderates in the early days and gradually deepens into stupor. In one case this process occupied nearly a week. The patients, of whom we had four, were brought to the hospital in varying degrees of stupor. They may lie in a sort of coma vigil, the head and eyes drawn to one side, and the Digitized by Microsoft® 52 A Clinical Study of Acute Poliomyelitis. eyes wide open and expressionless. The face has a pecuHar waxy mask-like immobility, although no seventh nerve paralysis exists. The head is drawn back a little, and from time to time an expression of annoyance, almost distress, crosses the features. Now and then a faint twitching or tremor passes over an extremity or the whole side. Yet, despite the coma-like condition, the patient can be rather easily roused by handling or prodding. There is almost immediate re- sponse and objection in the manner which has been so often seen in the other cases of this extraordinary disease, a displeased, irri- tated whine, and a vexed shrugging movement of the shoulder for- ward and upward, conveying quite distinctly the child's wish lo be let alone (figure 15). Other cases of this kind may show a more stuporous condition with partly closed eyelids beneath which moves a slowly rolling eyeball. These individuals may or may not have retraction of the head, and lie prostrated and somnolent. They bear a strangely similar resemblance to patients with tuberculous men- ingitis. Like the coma vigil cases, however, they can also be rather easily roused by manipulation or prodding, and lapse as quickly again into stupor when undisturbed. Still other patients behave as though heavily drugged, and carry out sharp commands by slow, lazy, intensely apathetic motions. An elevation of temperature is usually present in these cases. It seems to bear little relation, however, to the degree of stupor. Thus, one individual with a temperature of 99.6° F. was far more stupor- ous than another with a temperature of 104.2° F. Furthermore, the first case had a rise of temperature during the period of awaken- ing from the stuporous condition. As a rule, the stupor clears with considerable rapidity, after a duration of from three to six days. In one instance the patient after four days awoke as though from sleep, looked about in a bewildered fashion and then said she wanted to go home. The other cases regained normal mental condition more slowly, but the process occupied only a few hours. To| differentiate these cases from tuberculous meningitis is some- times almost impossible. If paralysis exists when the case is first seen, one inclines more perhaps to the diagnosis of poliomyelitis, but in the preparalytic stage there is often nothing to give a differ- Digitized by Microsoft® Frcmcis W. Peabody, George Draper, and A. B. Dochez. 53 ential clue. It is in these cases that the want of a specific reaction for poliomyeHtis in the spinal fluid is most keenly felt, especially if the first search for tubercle bacilli is negative. The negative von Pirquet reaction, which occurred in our cases, is also a distinct help towards ruling out tuberculosis. All of our cases of stupor have had lesions in the cord at high levels. Three had palsies of the facial nerve, and one had upper extremity paralysis. This case and one of the bulbar cases also had slight, transient lower extremity involvement. One individual had lost only the power to look down and to converge. The extraordinary thing about the inability to converge was that both internal recti acted well in conjugate lateral deviation of the eyes. From these various general clinical expressions of the acute stage of the disease, the patients recover more or less in the same way. As the acute symptoms pass, and the child begins again to take note of its surroundings and becomes cheerful, the paralyses, although previously observed, assume greater significance. Some cases show improvement more slowly than others. The children, as a rule, first become less drowsy and irritable. They will put out a hand into an offered palm or answer faintly in monosyllables. With some individuals, this change of interest comes toward the end of the first week; with others, not for two, three, or sometimes four weeks. This awakening, as it may be termed, is usually the begin- ning of improvement. From this time on, the convalescence is ■steady. Some cases seem entirely well in a day or two, while others gain in health and cheerfulness more slowly for a week or longer. It is in this period that certain interesting psychic phenomena have been observed. Some children have been sullen and unwilling to play or be played with. In many cases fretfulness and irritability have persisted, and these children cry on the slightest provocation and sob for a long while afterwards. Still other individuals, fewer in number, present a peculiar emotional instability. Often such children begin to cry for no apparent reason and a moment later, if their attention is diverted by some trivial occurrence, begin as suddenly to laugh and giggle in a typically hysterical manner (case 9, page 137). In general, however, the children rapidly regain normal psychic Digitized by Microsoft® 54 A Clinical Study of Acute Poliomyelitis. poise, although in some cases there is a nervous apprehension which lasts for weeks. Furthermore, they soon lose the tired, wilted look and become rosy and fat. It is often surprising to see how quickly a very sick child looks well again, and sits up in bed smiling and happy. In such cases, only when the coverlet is drawn back and the helpless extremities appear, does one fully realize what a damag- ing blow the infection has dealt. THE PARALYSES. We have endeavored to show that with the advance in the knowl- edge of poliomyelitis, there has been a gradual shifting of the point of view from which the disease is approached. While not many years ago paralysis was regarded as the essential feature, the one limportant element of the picture, and the accompanying general symptoms were more or less completely disregarded, the tendency •of present medical thought is towards the conception of poliomyelitis as an acute infectious disease which often leaves in its wake a variety of disabling end results. Poliomyelitis, then, is not synonymous with paralysis, and the Tole played by this secondary symptom in the clinical history of the disease is becoming relatively less important. The new knowledge of abortive cases and of the probable infectivity of the prodromal stage teaches us that satisfactory control of poliomyelitis must, in the end, depend on the recognition of cases wholly apart from the paralysis. Where, formerly, paralysis was the one diagnostic cri- terion, its onset may now be only confirmatory evidence of a previ- ously suspected diagnosis. If, however, paralysis is no longer con- sidered to be the whole disease, it is unquestionably the greatest part of it. Now, and until the complex problems of diagnosis and therapeutics are finally solved, the feature of the disease which will form the center of the picture will be the paralysis, its prominence being dependent in large part on our imperfect methods. The paralyses, while not considered of such primary diagnostic importance as they used to be, throw a good deal of light on the extent of the pathological process in the individual case ; they offer valuable diagnostic information in atypical cases ; and they so fre- quently dominate the clinical picture and constitute the whole of the Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 55 problem for the attending physician that they deserve a some- what detailed study. The relation between the clinical signs and the pathological process in the nervous system is not an especially close one. The clinical signs depend, of course, on the pathological lesions, but they do not represent with any accuracy the extent of the lesions. Post-mortem examination shows a pathological involve- ment of the gray matter over an area which is usually much more extensive than that represented by the muscular paralysis, and an involvement of the white matter which has usually called forth no symptoms at all. That large areas of gray matter can be affected without producing clinical symptoms may depend on too slight in- volvement, or on the fact that most muscles derive nerve fibres from several levels of the cord, and their functional capacity is thus en- dowed with a large factor of safety. The absence of clinical symp- toms depending on lesions in the white matter, even when these are extensive, is a necessary result of the coexistence of lesions of the anterior horn cells, for in the presence of a widespread lower motor neurone disturbance, evidence of upper neurone involvement will usually be masked. Thus, even when the typical anterior horn lesions of poliomyelitis are associated with a diffuse inflammatory reaction through the white matter of the cord, the predominating part of the clinical picture will be the flaccid paralysis of lower neurone destruction. One of the most characteristic of the general features of the paralyses in poliomyelitis is their peculiarly unsystematic distribu- tion. Thus, in one case both legs are paralyzed, in another one leg and one arm, in a third case there is a peroneal associated with a deltoid or perhaps a facial paralysis, bizarre combinations with no apparent anatomical or physiological basis. There is, of course, a definite tendency for certain parts of the cord to be involved more frequently than others. Lesions in the lumbar enlargement are by far the most common, and next in frequency are lesions in the cervical enlargement with resultant leg and arm paralyses. The fact that certain parts of the cord are more apt to be affected than others probably depends largely on the blood supply. The primary reaction to the virus being a perivascular infiltration, the extent of the inflammation will vary more or less with the size and number Digitized by Microsoft® 56 A Clinical Study of Acute Poliomyelitis. of the blood-vessels. That the lesion is most marked in the anterior horns of the gray matter is due to the fact that here, about the large motor nerve cells, the circulation is more abundant than in the posterior horns or in the white matter. Again, that extensive lesions are more frequent in the cervical and lumbar enlargements than at other levels of the cord is explained on an anatomical basis by the fact that the blood-vessels are largest and most numerous at the levels from which the great nerve plexuses arise. Other char- acteristics of the distribution of the paralysis, the affection of in- dividual muscles, the involvement of various groups of muscles, as well as the sparing of others, depend on the pathological lesion being located in the cord itself and not in the peripheral nerves. In other ways, too, the clinical picture and the pathological anatomy of poliomyelitis may be harmonized. Thus some paralyses are complete and permanent. In these there must have been an actual destruction of all or nearly all the nerve cells from which the affected muscles received nerve fibres. At other times one sees what is a weakness rather than a paralysis. This may be due either to an interference with nerve cell function by the pressure of exu- date and edema without actual destruction of cells, or, it may be due to the destruction of a limited number of cells. As Bing^" says, "Anterior root lesions, . . . unless very extensive, merely weaken and do not completely paralyze the muscle, owing to the fact that, as a rule, the muscle is innervated from several roots." Another class of paralyses is characterized by its transient nature. Either they last only a day or two, or they may persist for several weeks and eventually disappear. These are apparently the result, not of a destruction of nerve cells, but of a profound disturbance of func- tion by toxic influences, or by the pressure of exudate, edema, and hemorrhage. When the disease ceases to progress, and the repara- tive stage with absorption of exudate begins, there is a relief of pressure, and the cells are enabled to resume their normal function. The general manner of the onset of paralysis has already been considered. Some cases pass through a short period of muscular weakness corresponding to the beginning of the pathological '"Bing, Compendium of Regional Diagnosis in Affections of the Brain and Spmal Cord, translated by Arnold, New York, 191 1. Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 57 changes, but the onset is usually sudden and swift, and the damage is quickly complete. The history is apt to state that paralysis came on over night, but occasionally one obtains more accurate evidence as to the possible rapidity of onset. One of our patients, an adult twenty years old, after several days of prodromata, went to sleep at half past twelve in the afternoon. Until then she had moved her legs normally. At two o'clock, one and one half hours later, she awoke and found her right leg completely paralyzed. There was no progression of symptoms. The whole damage was done at one stroke. Other instances are on record of even more rapid onset. Not infrequently, however, the first paralysis is followed at an interval of hours or days by further advances, and in one typical class of cases the process, as we shall see, sweeps like a wave over the whole spinal cord. A discussion of the relative frequency with which different muscle groups are affected is of value only when a very large series of cases is analyzed. We, therefore, quote the following table from Wick- man. It represents 868 cases seen by him in 1905. 1. One or both legs 353 2. One or both arms 75 3. Combination of arms and legs 152 4. Combination of legs and trunk muscles 85 5. Combination of arms and trunk muscles 10 6. Trunk muscles alone 9 7. Paralysis of " the whole body " 23 8. Ascending paralysis 32 9. Descending paralysis 13 10. Combination of spinal and cranial nerves 34 11. Cranial nerves alone 22 12. Localization of paralyses not given 60 In 43.69 per cent, of the cases, the paralysis was limited to the legs. One or both legs were affected in 85.64 per cent, of all the cases. A second table prepared by Lovett and Lucas* ^ gives similar information (see page 58). In the following more detailed consideration of the various clin- ical types of lower motor neurone paralysis, we shall take them up from the anatomical point of view : first those dependent on cord " Lovett and Lucas, Jour. Am. Med. Assn., igo8, li, 1677. Digitized by Microsoft® 58 A Clinical Study of Acute Poliomyelitis. Duchenne, Scligmiiller, Lovett and Lucas. Sinkler, Starr. 1. Both legs 130 84 2. Right leg 216 '34 3. Left leg 239 133 4. Right arm S 3© 5. Left arm S 23 6. Both arms alone ° 9 7. All four extremities 3 Si 8. Arm and leg, same side IS 4^ 9. Arm and leg, opposite side 7 ^° 10. One arm, both legs 2 IS 11. Abdomen with other paralysis 6 lesions, next those with combined cord and bulbar lesions, and then those of purely bulbar origin. Finally, we shall describe the rapidly progressive cases as a class by themselves. Spinal Paralyses. Statistical studies show that in the great majority of cases of poliomyelitis, muscles of one or both legs are paralyzed, and that in nearly one half the cases the paralysis is limited to the legs. This corresponds to a pathological lesion in the lumbar enlargement of the spinal cord, and especially between the first lumbar and second sacral segments. Either one or both legs or any individual muscle may be affected. In the upper leg the quadriceps femoris is most often paralyzed, and in the lower leg the anterior group of muscles, the peroneals, the flexors of the foot, and the extensors of the toes, are most commonly involved. Extensive leg paralyses are of very frequent occurrence, but complete and permanent paralysis is not the rule. More often the flexors of the toes are spared, or if they are paralyzed immediately after the onset, they are usually the first muscles to show a return of function. On account of this relative immunity of the extensors of the foot and flexors of the toes, toe drop and contractures of the foot due to the unopposed pull of one group of muscles form a complication difficult to overcome. The paralyzed limbs are often cool to the touch and there may be a red- dish purple mottling of the skin. The feet especially are apt to be cold, and they may be covered with a cold sweat. In the paralyses of leg muscles, one sometimes sees, perhaps more often than else- Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 59 where, a remarkably late restoration of function after such a long period has elapsed that one has begun to fear that the paralysis was permanent. In our experience this has been especially noticeable in the flexors and adductors of the thigh. Sphincter paralyses, dependent on lower cord lesions, are prob- ably rare. Many cases have bladder disturbances, usually retention of urine, but the facts that this is transient, that it appears during the febrile period, and may begin before the onset of other paralysis, make it seem probable that this symptom is more often analogous to what is seen in other acute febrile diseases, rather than a result of cord involvement. The reports by other observers of more severe and more persistent sphincter disturbances make it almost certain that paralyses of the vesical sphincters do exist. A few of our cases have had to be catheterized, one during a period of several days. Bowel disturbances suggesting paralysis of the sphincters are much more unusual. In one case of an intelligent boy, it seemed that such a condition might be the cause of an ap- parent inability to control the bowels. Next in frequency to paralyses of the legs are paralyses of the arms, depending on lesions in the cervical enlargement of the oord from the fifth cervical to the first thoracic segment. In our series of seventy-one ward patients, thirty had involvement of the arms, but, as is usually the case, the great majority of them had a leg paralysis also. In only four instances the legs were not affected. Two of these showed an arm paralysis only; one had, in addition, a transient facial, and one a transient diaphragmatic paralysis. Ex- cept where arm lesions form a part of a very general paralysis, they are usually unilateral (case lo, page 138). We saw but one instance of both arms being afifected in the absence of any leg disturbance (case 9, page 137). There is a tendency, greater even in the arms than in the legs, for the paralyses to be limited to muscle groups. The shoulder muscles and more especially the del- toids are most apt to be involved. It is a generally recognized fact that the proximal muscle groups of the limbs, especially the upper limbs, are more apt to be paralyzed than the distal muscles, and that after paralysis, recovery is quicker and more certain in the distal than in the proximal muscles. The shoulders are paralyzed more Digitized by Microsoft® 60 A Clinical Study of Acute Poliomyelitis. often and their recovery is less certain. Elbow, hand, and finger muscles are less frequently affected and show a greater tendency to regain their power. Here, in analogy with the legs, one finds the flexors of the fingers less often involved and more completely re- covering than the extensors. Complete and permanent flaccid paralysis of the whole limb is unusual. A recovery of the flexors of the fingers almost always occurs. Transient weakness or a tem- porary paralysis of one or both shoulders, occurring as a part of a more general process, is often followed by complete return of func- tion, but if the paralysis persists and becomes well established, it appears to have an unusually bad prognosis. No muscle seems to atrophy as fast as the deltoid. One rather peculiar symptom com- plex was observed in association with an arm paralysis. The child had at first a complete flaccid paralysis of the left arm, but it gradu- ally abated, with return of power in the triceps and extensors of the fingers, and to some extent in the flexors of the fingers. With this was noted failure of the left pupil to dilate, narrowing of the left eye slit, hemicranial sweating, the left side of the face being nearly dry, and hemicranial vasomotor phenomena. These symptoms de- pended apparently on a lesion of the ciliospinal ganglion which is situated in the cord at the level of the eighth cervical and first thoracic segments. The flexor muscles which showed such a de- layed return of power derive their nerves principally from the seventh and eighth cervical, and first thoracic segments (case 15, page 147). When the pathological process is fairly definitely limited to the cervical cord, and the legs are not paralyzed, one often observes a tendency to hold the legs stiffly, an exaggeration of the knee jerks and ankle reflexes, and a peculiar transient spastic ataxia of the legs. These symptoms certainly suggest an upper neurone disturbance and it seems probable that they are due to an involvement of the pyramidal tracts or of Clarke's columns, where these pass through the cervical region. Paralysis of the Diaphragm.— In the upper part of the cervical cord, in the third, fourth, and fifth cervical segments, and in general above the area from which the brachial plexus arises, lie the cells whose axones form the phrenic nerve and innervate the dia- Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 61 phragm. Owing to the fact that the phrenic nerve has a large number of roots, or to some peculiarly fortunate circulatory condi- tion, comparatively rarely is this area so severely affected that the action of the diaphragm is interfered with. Among fatal cases, however, this is not true, for practically all cases that die of polio- myelitis, without complication, die of respiratory failure, and respi- ratory failure means paralysis of the intercostal muscles and the diaphragm. It is noteworthy that among our fatal cases the dia- phragm was usually the last to be affected, paralysis of the inter- costals often preceding it by many hours. Owing to the vital im- portance of the diaphragm, its paralysis makes a serious prognosis, but recovery not infrequently takes place. We have seen two in- stances of paralysis of the diaphragm lasting for over a week and ending in complete return to normal. In one case it was associated with a paralysis of both arms, and in the other with an extensive paralysis of neck, arms, abdomen, and legs. In neither of these children was there any marked respiratory disturbance, but the picture was perfectly typical. Respiration is wholly thoracic, and sometimes the accessory muscles of the neck come into play. The abdominal wall moves with each respiration, but instead of its normal inspiratory protrusion, there is the typical inspiratory retrac- tion depending on the lax diaphragm. Firm pressure on the sides of the thorax fails to induce any abdominal breathing and causes rapid, labored respiration. A condition which may be temporarily confounded with diaphragmatic paralysis is the type of breathing sometimes seen in crying or sobbing children ; respiration is usually irregular, thoracic, and associated with an inspiratory retraction of the abdomen. This, of course, passes off as soon as the child be- comes quiet again (case 13, page 143; see also case 9, page 137). Paralysis of the Intercostal Muscled. — The thoracic portion of the spinal cord, probably owing to its less abundant blood supply, is also comparatively rarely attacked, except in the overwhelming infec- tions terminating fatally. In such cases there is usually a progres- sion upward from the lumbar region or downward from the cervical region, and the paralysis of the intercostal muscles which follows the invasion of the dorsal cord is one of the factors that cause respiratory failure and death. While the majority of cases with Digitized by Microsoft® 62 A Clinical Study of Acute Poliomyelitis. paralysis of the intercostals end fatally, we have seen three instances of recovery. In two there was an associated paralysis of both arms and legs, and in one other of legs and abdominal muscles. The two former still showed an intercostal paralysis on discharge from the hospital, several weeks after the onset of the disease. In the latter there was return of function. In a fourth, seen in the dispensary, the associated leg paralysis cleared up almost entirely, but a complete intercostal paralysis persisted. Atrophy of the chest muscles, nar- rowing of the chest, and protrusion of the abdomen make a pecu- liarly characteristic late clinical picture (see figure i6),. In some cases there has been an association of intercostal paralysis with edema of the lungs. The presence of coarse, moist rales in both lungs in the absence of fever and of cardiac weakness, and in the absence of evidence of a bronchopneumonia at autopsy have made us feel that the process may possibly be one of vasomotor origin. The diagnosis of paralysis of the intercostal muscles is less simple than that of the diaphragm, for in many children the normal type of respiration is almost wholly diaphragmatic and suggestive of weak- ness of the intercostals. In typical paralysis of the intercostal mus- cles, respiration is wholly abdominal, the thorax moves very slightly, its movement on inspiration being downward and backward instead of forward and upward. There is sometimes a sucking inwards of the intercostal spaces and, in children with flexible chest walls, of the lower part of the chest on inspiration (figures i6 and 17). Pres- sure over the abdomen does not induce a thoracic type of respira- tion, but it causes rapid, labored breathing, an effect not produced by compression of the chest. Both intercostal and diaphragmatic paralyses predispose to the development of bronchopneumonia (cases 14, 15, and 16, pages 145, 147, and 149). Paralysis of the Abdominal Muscles. — The statements of various observers show a great divergence of opinion as to the frequency of paralysis of the abdominal muscles. From a study of our own cases, we have felt that an accurate estimation of its occurrence is extremely difficult, for the diagnosis in an acutely sick child of a transient weakness or paralysis of the abdominal wall is by no means easy. It is readily simulated by soft, atonic abdominal muscles. Apart from these transient paralyses, which undoubtedly Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 63 occur frequently, and from the involvements in rapidly fatal cases, there is an interesting class of abdominal paralyses which usually persist. These consist in either local areas of weakness or general paralyses of the abdominal muscles on one or both sides. The ex- ternal and internal oblique muscles and the transversalis are usually involved together. The rectus abdominis is usually spared. Some- times all the muscular sheet outside the rectus is weak, and there is a bulging of the sides of the belly, but more often the paralysis is localized, and there is a circumscribed protrusion of the wall resem- bling an abdominal hernia. These paralyses are brought out more definitely by coughing, by crying, or by attempting to raise the body in bed (figures i8 and 19). Paralysis of the abdominal muscles may be the only symptom that persists. Paralyses of the Neck and Back Muscles. — These have been most common in our patients in severe cases with extensive paralyses. In most of them there has been involvement of both arms and legs, associated with that of the back and neck. In one case, however, the only paralysis ever noticed was a transient affection of the neck (case 17, page 151). Muller calls especial attention to the great fre- quency with which paresis of the trunk muscles occurs early in the disease. We have found the back muscles very difficult to test early in the acute stage, for the children are often either so sick or have so much pain that they will not try to support the spine. More- over, it is hard to distinguish whether weakness of the back is caused by a spinal cord lesion, or is merely a general symptom. In paralysis of the neck muscles, the child cannot support its head, which falls helplessly forward, backward, or to one side. Paralysis of the back muscles is either unilateral or bilateral. In the former case the child may be able to sit up, but the spine bends with its convexity towards the weak side. If the lesion is bilateral, the patient cannot support the trunk and it falls backward, sideways, or forward, so that the body doubles up on top of the legs. Except in a few very extensive cases, paralyses of the neck and back muscles tend to disappear early. Digitized by Microsoft® 64 A Clinical Study of Acute Poliomyelitis. Bulbospinal Paralyses. It is probable that in most cases of poliomyelitis the patholog- ical changes in the central nervous system are much more exten- sive than the clinical picture would lead one to suspect, and that scattered areas of exudate or hemorrhage are often present in the medulla and pons. In a smaller proportion of cases, but not infre- quently, these lesions are large enough and so situated as to produce definite symptoms by involvement of the nuclei of the cranial nerves. Most commonly the cranial nerve affections form part of a general process in vifhich the cord is simultaneously affected, but in a small proportion of cases the lesions of the cord are so slight as not to cause paralyses, and the clinical picture is that of an acute bulbar paralysis. Most instances of combined spinal and bulbar paralyses have extensive lesions involving legs, arms, and regions supplied from the bulb. Localized processes in the bulb and upper cord are much less frequent. Both where the cranial nerve affections occur alone, and where they are associated with spinal cord lesions, they are almost always unilateral. Bilateral bulbar involvements are extremely rare. Pathologically, as we have seen, the spinal and bulbar paralyses have the same basis. Clinically, too, though they may pre- sent quite different pictures, it is impossible to separate them, as one type merges gradually into the other. The greater number of cases form the intermediate type with both spinal and bulbar paralyses. In the Swedish epidemic of 1905, in which there were 685 cases, Wickman saw forty-two instances of combined spinal and bulbar paralysis. In the series of seventy-one cases which we have ob- served in the hospital there were, excluding the fatal cases, twelve of combined paralysis. The fact that our figures are proportion- ately nearly three times as large as Wickman's probably depends on the possibility of closer observation afforded in a hospital. Many of the cranial nerve paralyses were comparatively slight and tran- sient, so that constant watching of the children was necessary for their detection. It was quite noticeable that the bulbar paralyses occurring in association with spinal paralyses were much less severe and less likely to be permanent than when they occurred alone. As has been the experience of other clinicians, we have found the Digitized by Microsoft® Francis W. Peabody, George Draper, and A, B. Dochez. 65 facial nerve most often affected. A facial paralysis occurred in eight of the twelve cases with both cord and bulb lesions, but in almost all it was slight and disappeared quickly. In three of the four cases of purely bulbar paralysis, facial paralysis was present and improved very slowly. Either the whole facial nerve or one branch may be affected (figures 20, 21, and 22),. Ocular palsies were present four times in the hospital cases. In agreement with the findings of Wickman and Miiller, we have found an abducens paralysis to be the commonest ocular palsy. Paralysis of the ocular muscles was sometimes transient, but often apparently per- manent. One case seen in the dispensary had at first a paralysis of the right leg and of the right external rectus. Four weeks after the acute onset of the disease the leg had almost com- pletely recovered, and the only evidence of the disease was a well marked internal squint. It is perhaps worth considering whether slight attacks of poliomyelitis may not be a more fre- quent cause of strabismus than is usually recognized. More ex- tensive palsies and even complete ophthalmoplegia externa have been reported by Wickman. Nystagmus was noted several times in the early part of the acute stage of the disease. The eye grounds were examined in many of our cases, but we found no abnormalities of the optic nerve. While Wickman has reported one instance of optic neuritis in an acute case, and Tedeschi (quoted by Wick- man^^) found complete blindness and optic atrophy of the left eye in a chronic case, Miiller failed to find any evidence of optic neu- ritis or choked disc in a large number of acute cases, and he believes that if either is found, the case is almost certainly not one of polio- myelitis. Disturbances of speech and phonation are quite frequently met with ; the latter may be of all degrees from hoarseness or slight weakness to complete aphonia. They usually occur very early in the course of the disease and are transient, though we have seen them be- come progressively worse during the second week, and in one case the mother said that the child could not talk for nine days. Difficulties of deglutition are sometimes seen at the acute onset of the disease. This may be a transient symptom which lasts a day or two and con- sists only in an inability to swallow solids. In other patients, as "^Wickman, Die akute Poliomyelitis, loc. cit. Digitized by Microsoft® 66 A Clinical Study of Acute Poliomyelitis. in two purely bulbar cases to be described, there may be total in- ability to swallow, lasting for many days and necessitating feeding by gavage. While the situation appears at the time to be most seri- ous, the tendency to recovery, according to our experience, seems to be much better than one would expect, and return of function may take place even after ten days of paralysis. In progressive fatal cases, a paralysis of swallowing is frequently seen. Disturb- ances of speech and disturbances of swallowing often occur together. With paralysis of deglutition may be associated a paralysis of the hypoglossal nerve. This is usually a unilateral lesion causing in- ability to protrude the tongue straight, but cases of bilateral involve- ment with complete inability to protrude the tongue are reported. In the two of our cases which had prolonged difficulty in swallow- ing, but which finally became normal in this respect, a persistent hypoglossal paralysis remained as a residual lesion. In a dispensary case, the only bulbar symptom remaining several weeks after the onset was a deviation of the tongue with an atrophy of one half of it. Atrophy of the intrinsic muscles of the tongue occurs quite rapidly after hypoglossal paralysis, but no interference with func- tion is apparent. Evidence of involvement of the vagus nerve in poliomyelitis will be shown in the consideration of the progressive fatal cases. Two fatal cases showed spinal fluids which had an exceptionally high power of reducing Fehling's solution. One of these had also a glycosuria. It is possible that an inflammatory lesion between the nuclei of the eighth and tenth nerves had the same effect as the " sugar puncture " of Claude Bernard and caused a hyperglycemia. One of the most interesting clinical forms in which poliomyelitis appears is that of the purely bulbar paralysis. Until Medin's publi- cation, the relation of cases with affections limited to the cranial nerves to the typical poliomyelitic cases had not been definitely brought out. There is now, however, abundant evidence, both pathological and epidemiological, to show that many cases formerly called acute bulbar paralysis are, in fact, poliomyelitis with a local- ized lesion in the pons and medulla. This type of case is not especially uncommon. We have had four instances under observa- tion in the hospital and have seen other acute cases in the dispensary. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 67 We have already called attention to the fact that the paralysis in these cases tends to be more severe and more lasting, than are the bulbar paralyses when they occur in association with general cord lesions. Except for the residual paralysis, however, the prognosis seems to be good. One might expect to see death from involve- ment of some of the higher centers, but this has not occurred in our experience, nor have we noted any tendency for a bulbar paralysis, once definitely established, to spread to the phrenic or upper cervical centers. Any of the cranial motor nerves may be affected, and the combinations in which various nerves are involved are numerous. As usual, the facial nerve is most frequently paralyzed, and a facial palsy may be the only evidence of the disease. In one case we found a paralysis of the sixth, seventh, and twelfth nerves, and complete inability to swallow. After being fed by gavage for five days, the patient regained the power of deglutition, and later the strabismus disappeared. The facial and hypoglossal paralyses persisted. In another bulbar case the only evidences of paralysis were inability to swallow, deviation of the tongue, and hoarseness of the voice. Feeding by gavage was continued for ten days. During this time the patient's general appearance became worse and his hoarseness was suddenly succeeded by almost complete aphonia. At this time, when he was very weak, sixteen days after the onset of the disease, he suddenly showed some return of the ability to swallow, and small amounts of food were given by mouth. Recovery of voice and deglutition proceeded uninterruptedly and the child was dis- charged perfectly well except for a residual paralysis of the right hypoglossus nerve. Quite characteristic of these high lesions has been an ataxia which has become evident when the children were well enough to begin to use their arms and legs. Knee jerks and Achilles reflexes are greatly exaggerated, and the legs may be held stiffly. The gait suggests somewhat a spastic ataxia. The children have difficulty in balancing themselves, a well marked Romberg sign may be present, and they walk with rather stiff legs and feet spread wide apart. This is a temporary condition and, after they have been on their feet for a few days, the gait becomes normal, but the exaggeration of reflexes often persists much longer. The cause of this phenomenon is difficult to determine with accuracy. Digitized by Microsoft® 68 A Clinical Study of Acute Poliomyelitis. It may be due to lesions in the cerebellum, in Clarke's columns, or in the pyramidal tracts as they pass through the bulb or upper cord (cases i8, 19, 20 and 21, pages 152, 154, 155, and 158). Rapidly Progressive Cases. From the pathological point of view, there is no reason for con- sidering separately those cases of poliomyelitis in which there is a progressive involvement of the nervous system, for the lesions are in themselves similar to those found in other cases. Clinically, however, they have formed such a characteristic group in our experience that it is convenient to discuss them by themselves. They constitute the greater number of fatal cases. Many, if not all cases showing the symptom-complex known as Landry's paralysis, belong to this group of poliomyelitis. There are in gen- eral two ways in which death occurs in poliomyelitis. Either it is due to a complication, for the most part bronchopneumonia, arising in the already injured system, or it is due to paralysis of the muscles of respiration. We have seen that a patient can live and can even recover after a paralysis of either the diaphragm or the intercostal muscles. When both become paralyzed, respiration ceases and death ensues. The fatal issue depends not on the nature of the pathological process, but on its location. If certain vital parts are spared, the extent of the disease seems to have little effect on the general health. The essential feature of death in poliomyelitis is that it is a respiratory and, in a way, a mechanical death. In most other acute infections we regard death as being due to a toxemia. The body becomes overwhelmed by a poison which interferes with its functions, until finally some organ, usually the heart, weakens and fails. That a toxic substance plays some role in the destruction of the nerve cells in poliomyelitis cannot at present be disproved, but that anemia and pressure play a very striking part is certain. The typical clinical picture, moreover, as we have seen it in the severe, fatal cases, is not that of a patient dulled by a general toxemia, but of one with a clear, alert sensorium, fighting for every breath until he is literally suffocated. This does not mean, of course, that there are not other cases of poliomyelitis which pass from somnolence to stupor and die without regaining consciousness. Whether, in such Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 69 cases, the mental condition is a toxic affect, or whether it, too, may not also depend in large measure on the mechanical action of the poliomyelitic process involving the centers of consciousness, is a question which we feel cannot be answered at present, but there is much to make the latter suggestion seem not improbable. The average mortality for different epidemics of poliomyelitis varies between lo and 20 per cent. Of the cases which we have followed in the hospital ten, or about 14 per cent., died. In three of these death was due to bronchopneumonia supervening on an extensive paralysis which included either the intercostal muscles or the diaphragm. In seven cases there was no evidence of any com- plication, and death was the result of poliomyelitis with paralysis of the respiratory muscles. We have seen that in most cases of poliomyelitis the paralysis is sudden and severe, and reaches its maximum in a comparatively short time. The same may occur in fatal cases. In one case seen outside the hospital, there was a sudden overwhelming paralysis which caused death within five hours after its onset. In the majority of cases, however, after the acute onset of a more or less widespread paralysis which usually involves either the intercostals or the diaphragm, there is an interval of a few days with a pause or a slower progression in the paralysis until there is a weakening and a final cessation of respiration. The typical Landry's paralysis is an ascending paralysis involving first the legs, then the intercostals, arms, neck, and diaphragm. In most cases the picture is not quite so clear cut, for the primary paralysis is more extensive and involves both arms and legs, but in six of the seven uncomplicated, fatal cases, the intercostals were first affected, and death followed the failure of the diaphragm. In the three cases which had a terminal bronchopneumonia, however, there was a primary paralysis of the diaphragm. The majority of the uncomplicated cases conformed closely to the ascending type of Landry's paralysis. One only was of the descending type with early paralysis of the diaphragm and terminal involvement of the intercostals. In the fatal cases, then, as well as in those that recover, there is usually a pause after the acute onset of the paralysis. There may be one or two days without any definite increase in paralysis, but it Digitized by Microsoft® 70 A Clinical Study of Acute Poliomyelitis. is frequently noticeable that the children are not doing so well as those who will eventually recover. Often the respiration is more rapid and a trifle more difficult than the degree of paralysis war- rants. They are frequently unusually nervous, excitable, and irri- table. Then the paralysis may begin to increase. A laryngeal disturbance with hoarseness, aphonia, or difficulty in swallowing may be the first evidence of the spreading lesion. A weakening of the remaining muscles of respiration soon follows. If the inter- costals are still active, the movement of the chest becomes less marked. If the diaphragm has hitherto been intact, its movement, as represented by the abdominal wall, becomes weaker, or there is an asymmetrical movement suggesting a paralysis of one side of the diaphragm. Respiration becomes more rapid, more labored, and perhaps irregular. Instead of the normal smooth, rhythmic cycle, there may be a sharp, jerky, forcible movement of the abdominal wall on expiration. Pressure over the abdomen causes distress and interference with breathing. The alse nasi dilate with inspira- tion, and the accessory muscles of respiration in the neck begin to come into play. As the diaphragm weakens, the neck muscles become more and more prominent until it seems as if the whole work of breathing depended on them. The sternomastoids pull on the clavicle, and in one case they caused a partial dislocation of the sternoclavicular joint with each inspiratory effort. The head is thrown back, and with every breath the lower jaw is pushed forward and downward in a gasping attempt to get air. Occa- sionally, there is typical Cheyne-Stokes respiration, probably de- pendent on a lesion of the nucleus of the pneumogastric nerve. Meanwhile the lungs may have remained perfectly clear until the very end, or a few hours before death coarse, moist rales may accumulate, an edema suggesting vasomotor paralysis. The heart is sometimes strong and regular until it stops. Usually it continues beating for a considerable period after the cessation of respiration. Heart sounds have been audible for as much as five minutes after breathing stopped, and electrocardiographic records showed that stimulus formation continued for twenty-three minutes after cessa- tion of the sounds. Several times a characteristic arrhythmia has set in for the last few hours of life. The heart beats perfectly Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. 71 regularly and then suddenly changes its rate; jumps from perhaps one hundred per minute to one hundred and forty, remains regular at this rate for a few beats and then, possibly with a few interpolated irregular beats, drops back again to its former slow rate and regular rhythm (figure 14). In one instance the rate dropped from eighty- four to thirty-six and then varied between these two. This rhythmic arrhythmia may persist or it may give way to a regular rhythm and return later. It is apparently a so-called sinus-arrhythmia, and prob- ably represents a vagus nerve disturbance. Records taken with the electrocardiograph show a condition which is quite similar to that described by Luciani as occurring in the heart of the asphyxiated frog. It is interesting that in one case, in association with the institution of artificial respiration and a lessening of cyanosis, the. irregularity of heart action completely disappeared. Fever was present in all of the fatal cases when they were ad- mitted to the hospital. In most of them it varied between 101.5° and 103.5° F- ^^ two cases it did not run over 100° F. The course of the temperature, however, was not unlike that seen in cases ending in recovery. In general, it was highest on the first day of paralysis, lower on the next day, falling approximately to normal by the day of death. There has been no tendency for the usual fever curve to be prolonged in the fatal cases. The most remarkable feature of our fatal cases was the condition of the sensorium. Three of our patients were so young that ob- servations on their mental state were not of value, but four, between the ages of three and a half and ten years, showed a very interest- ing and comparatively constant picture. We have already called attention to the apparent absence of toxic effects in many cases of poliomyelitis, and this is nowhere more strikingly illustrated than in these severe, fatal cases. During the prodromata, and often during the acute onset of the early paralysis, the children may be sleepy and drowsy in the manner which is characteristic of so many cases. This condition is, however, apt to be mild and transient and it is often soon replaced by a clear mental state. With the onset of respiratory difficulty, it seems almost as if the children were sud- denly awakened and made to realize the struggle before them. Little children seem to age in a few hours. One sees a heedless, Digitized by Microsoft® 72 A Clinical Study of Acute Poliomyelitis. careless, sleepy baby become all at once wide awake, high strung, alert to the matter in hand, and this is, breathing. The whole mind and body appear to be concentrated on respiration. Respiration becomes an active, voluntary process, and every breath represents hard work. The child gives the impression of one who has a fight on his hands, and who knows perfectly how to manage it. All he wants is to be left alone, not to be interfered with, to be allowed to carry out his fight on his own lines. Instinctively he husbands his strength, refuses food, and speaks, when speech is necessary, quietly and with few words. One little child of four, so helplessly para- lyzed that she was unable to move, but with a mind that seemed to take in the whole situation, said to the nurse clearly but rather abruptly, between her hard-taken breaths, " My arm hurts " ; " Turn me over " ; " Scratch my nostril " ; and then when the doctor ap- proached, " Let me alone, doctor ! " ; " Don't touch my chest." Pressure on the chest, tight neck bands, anything that obstructs easy respiration is immediately resented. The child demands constant attention, is irritated unless everything is done exactly as he wishes it, and often shows an instinctive appreciation for some especially efficient nurse. He is nervous, fearful, and dreads being left alone. The mouth becomes filled with frothy saliva which the child is unable to swallow, so he collects it between his lips and waits for the nurse to wipe it away. He likes to have his lips wet with cold water, but rarely attempts to take it into his mouth, for he knows he cannot swallow it. During the whole course it is remarkable that cyanosis is absent. There is a little bluish tingeing of the lips and tongue, but much more distinctive is the pallor, which is some- times striking. Sweating is profuse. Then, as respiration gets weaker, the mind becomes dull, and with the occasional return of a lucid interval, he gradually drifts into unconsciousness. An hour or more later respiration ceases. This peculiarly alert, keen mental state has been much less noticeable in small babies. They tend to be dull and drowsy most of the time; but in the older children this alertness has been such a characteristic feature of the fatal cases, that we almost preferred to have a child brought to us in a stuporous condition, rather than with a mind whose nervous acuity seemed due to a perception of impending danger (cases 22, 23, 24, 25, 26, 27, and 28, pages 160, 161, 163, 165, 168, 171, and 173). Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 73 Cases 29 and 30 (pages 174 and 176) died of a terminal broncho- pneumonia. Cerebral Type. In a masterly article, Striimpell,^^ in 1885, first called attention to the analogy between certain forms of cerebral paralysis in chil- dren and poliomyelitis. For this group of cases he suggested the name polioencephalitis. In the twenty-four instances analyzed by him, the disease occurred in nineteen cases below the age of four. None of the children were over six years old. In general the onset was sudden, and there was an initial stage with fever, vomiting, and convulsions. The last was the most frequent initial symptom. A prodromal period seemed to be wholly wanting in certain cases ; in others it lasted two or three days, and in some instances it extended over several weeks, during which there were constant convulsive seizures. After the prodromal period, the child was found to have a hemiplegia. The paralysis usually began to improve shortly, but a limp and, more often, disturbed function of the arm usually per- sisted. The face was less often and less severely affected than the arm or leg. Strabismus occurred in several cases. Monoplegic paralysis of arm or leg, or even an ataxia without actual paralysis, was occasionally the only disturbance. There was no atrophy of the muscles or reaction of degeneration. The reflexes were usually exaggerated. Athetosis, epilepsy, disturbances of speech and intel- ligence sometimes occurred as sequelae. In his discussion of the analogy between this type of case and poliomyelitis, Striimpell says it is noteworthy that, " in both diseases the chief seat of the lesion is the gray matter, in one case in the gray matter of the anterior horns, and in the other in the corresponding portion of the cerebrum, the cortex." When, in 1898, Medin^* published the first comprehensive de- scription of the epidemic form of poliomyelitis, he was able to include the reports of three cases with fever, somnolence, convul- sions, spastic hemiplegia, and exaggerated reflexes, and of a fourth in which apparently both cerebral hemispheres were affected. In " Striimpell, loc. cit. "Medin, Arch. mid. des enfants, 1898, i, 257, 321. Digitized by Microsoft® 74 A Clinical Study of Acute Poliomyelitis. two instances the sixth cranial nerve was also paralyzed, and this bulbar affection formed a connecting link between the spinal and encephalitic forms. This, and the occurrence of both spinal and cerebral paralyses in the same epidemic convinced him that they had a common cause. Harbitz and Scheel described a case of acute encephalitis in a man thirty-nine years old. After an onset with headache, fever, and sweating, stiffness of the neck, vomiting, and convulsions set in. The patient was unconscious. All the limbs could be moved, but they were rigid, and the patellar reflexes were exaggerated. The tongue deviated to the left. The man died, and at autopsy macro- scopic circumscribed encephalitic or meningoencephalitic lesions were found in the right temporal lobe and in the gyrus fornicatus on both sides. Microscopically the lesion was more widespread and involved the central ganglia and medulla. In the spinal cord there was meningeal infiltration, but there was no definite inflammation of the anterior horns except in the cervical region. "Histologically, the inflammatory process resembled acute poliomyelitis in all its details." These three sets of observations, the first two of which at least are of historical importance, give a fairly definite outline of what is to be considered as the cerebral form of poliomyelitis. The classification of this type rests, as far as possible, on an anatomical basis. These are cases in which the predominating pathological lesion is in the brain itself, and in which the clinical manifestations suggest a disturbance of the upper motor neurone. The identity of the cerebral form of the disease has, as we have already stated, been greatly obscured by the tendency of many authors, especially English and American, to use inaccurately the terms cerebral or encephalitic. The frequent application of these terms to cases which show certain general symptoms, such as stupor, delirium, or meningism, has led to much confusion. That the term cerebral as applied to this disease has reference to the supposed anatomical seat of the lesion, and that the cases form a fairly definite clinical group, is shown by a glance at the historical basis on which the classifica- tion has developed. It will often, however, be difficult to draw a hard and fast line between what shall be called spinal and what Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 75 cerebral cases. Clinically as well as pathologically, the types must , merge. It would seem best to be governed by the most prominent symptoms. A case with a spastic hemiplegia would be classed as cerebral, even if it were associated with a slight nuclear paralysis of the sixth nerve; and a case with flaccid facial and arm paralysis would certainly be of the bulbospinal type in spite of showing a somewhat ataxic gait and exaggerated knee jerks, which might point to upper neurone lesions. After all, classification is purely artificial, and the real reason for making a separate class of these cases is to call attention to the fact that the virus of poliomyelitis may cause symptoms of cerebral rather than of spinal origin. In spite of the acknowledged fact that small scattered lesions are not uncommonly encountered as autopsy findings in the brain in poliomyelitis, the occurrence of extensive cerebral involvement has rarely been demonstrated. Moreover, the final proof that typical cerebral paralyses may have the same etiology as poliomyelitis can be obtained only experimentally. As yet the virus has not been shown to exist in typical polioencephalitis by transference of the disease to monkeys. Anderson and Frost,^^ however, report that the blood serum of a patient who had a paraplegia of the legs, at first flaccid, but in a few days becoming spastic, was able to neutralize active virus. It is rather remarkable, too, that, in spite of the fact that monkeys are usually inoculated intracerebrally, the paralyses are always spinal and not cerebral. The evidence, however, of the identity of the two diseases is still largely clinical and consists in the finding of cerebral cases during the course of typical epidemics, and of finding both flaccid and spastic paralyses in the same patient. Thus both Mobius^^ and Hoffmann^'' saw instances of flaccid and spastic paralysis occurring in members of the same family. Much more striking, however, than that a number of such suggestive in- stances have been observed, is the fact that, with the tremendous in- crease in the incidence of poliomyelitis during the past few years, and with its more general recognition, there has not been a cor- responding increase in the number of true cerebral cases reported. °° Anderson and Frost, Jour. Am. Med. Assn., 1911, Ivi, 663. "Mobius, Schmidt's Jahrb. d. ges. Med., 1884, cciv, 135. "Hoffmann, Miinchen. med. Wchnschr., 1904, li, 225. Digitized by Microsoft® 76 A Clinical Study of Acute Poliomyelitis. The majority of those reported as cerebral or encephalitic cases do not conform with the anatomical standard that has been laid down. Wickman, who has probably had a wider experience than anyone, states that during the great Swedish epidemic of 1905 he did not see any definite cerebral cases. Krause, in the Westphalian epidemic of 1909, saw one case with encephalitic features. Zap- pert, whose studies include 555 cases, saw only five instances of cerebral hemiplegia. MuUer reports four cases with spastic pa- ralyses, but states that in none of them was there conclusive evidence that the condition was due to a polioencephalitis of the cerebrum. He believes that the symptoms depend rather on an involvement of the pyramidal tracts in the bulb or cord. One case only might have been due to a disseminated encephalitis, — a boy who developed a complete right-sided hemiplegia, and, in addition, a few days later, a left-sided spastic paralysis. Such a case would fall in line with the fact that the lesions of the brain as observed at autopsy are always bilateral. In our own series of cases we have seen no example of a typical polioencephalitis. One case, however, showed a picture which was so suggestive of cerebral involvement that we are inclined to believe that it belongs to this group. A boy of four years and three quarters was taken sick with fever and vomiting. He became somnolent and when first seen was in an almost stuporous condition. The eyes showed a slight external strabismus on the left, and there was an inability to converge or to look downwards, which, according to our ophthalmological consultant. Dr. Schirmer, depended not on a lesion of the eye muscle nuclei, but on a higher coordinating center. There were no other paralyses. The Oppenheim sign was positive on both sides, and the Babinski reaction was suggestive. As the child came out of his stupor, the knee jerks became exaggerated, and a marked ataxia of arms and legs was observed. The diagnosis in this case was made more certain by the fact that the child's infant cousin, who had been in bed with him during his sickness, later developed a typical poliomyelitis (case 31, page 177). During the past season, we have seen but one case of cerebral hemiplegia in a child. The conformity of the history and of the course of the process in this instance to the cases cited byStriimpell Digitized by Microsoft® Francis W. Pedbody, George Draper, and A. B. Dochez. 77 were quite striking, but the chief interest in the case lies in the fact that, while occurring at a time when there was much poliomyelitis in the vicinity, we have good evidence in support of a dififerent etiology. The child, a little girl of three years, hitherto perfectly well, was noticed to be feverish and out of sorts on the morning of October 4th. She played during the day but in the evening she had high fever, reaching 105.2° R, and after taking some milk, vomited. Shortly afterwards she was taken with convulsions which were so prolonged and so severe that the attending physician gave her some chloroform. When she quieted down, her left arm was found to be limp. The next day a left-sided facial paralysis, with paralysis of the left arm and leg, was observed. Improvement began quickly, especially in the leg. When seen by us, thirteen days after the onset, her left leg was practically well, but a well marked facial paralysis persisted, and there was ataxia and incoordination of the left arm. The knee jerks and Achilles tendon reflexes were active on both sides ; there was no Babinski reflex and no Oppenheim sign. The eye grounds were negative. Lumbar puncture was done and the spinal fluid found to be absolutely normal. After a little over three weeks, a specimen of blood was taken, the serum mixed with active virus of poliomyelitis (o.i of a cubic centimeter and 0.3 of a cubic centimeter in two experiments), the mixture incubated and injected into two monkeys. Both monkeys became sick at about the same time as the controls, and at autopsy showed lesions characteristic of polio- myelitis. The serum had no power of neutralizing the virus, and the case was, therefore, probably not one of poliomyelitis. The many features which this case has in common with those described as polioencephalitis, and its occurrence in association with other typical cases of poliomyelitis, made the test of considerable interest. ABORTIVE TYPE. The term " abortive " was applied by Wickman to those instances of poliomyelitis which do not develop paralysis. Certain border line cases with slight weakness but no true paralysis, Muller has called "lavierte" or "embryo" types. This seems perhaps an unneces- sary distinction, especially in view of the new conception of the disease as a general systemic infection. As long as the cerebro- Digitized by Microsoft® 78 A Clinical Study of Acute Poliomyelitis. spinal tract was held to be the only seat of the malady, and paralysis was considered its usual manifestation, the word "abortive" for unparalyzed cases was entirely satisfactory ; but since recent develop- ments in the pathology of poliomyelitis have demonstrated a gen- eral disease affecting the lymphatic apparatus and many of the parenchymatous organs as well, there is some chance of a misunder- standing of the term. The case which fortunately escapes paralysis is as much a true example of acute poliomyelitis as the paralytic, and as a source of contagion it is more dangerous. Indeed there are certain scattered facts gleaned during the past decade by clinicians and laboratory workers which, when brought together to bear upon the question, indicate that the non-paralyzed cases are possibly the more usual, and that the paralyzed ones are less frequent forms of the disease. Wickman, for example, found in his large epidemiological studies that the abortive cases represented from 25 to 56 per cent, of the total incidence of the disease, but he states that these figures are probably too low. Miiller also believes such figures to be too low. He considers that the unparalyzed cases considerably outnumber the paralyzed. This view receives striking support from the recent demonstration of typical visceral lesions indicating that there is a general systemic infection. With such pathological find- ings, symptoms such as fever and malaise are reasonably to be ex- pected. It may be that the abortive cases are those in which this general process is present, but in which the nervous system has been spared. Netter and Levaditi^® have demonstrated that the serum of abortive cases neutralizes the virus in vitro, just as does the serum of the patients that develop paralysis. It is quite probable that in the past many of the abortive cases have been unrecognized and in certain cases at least, the apparent immunity of adults may be de- pendent upon such a previous, unrecognized attack. That the neu- tralizing substance in the blood may persist for a long period follow- ing an attack of the disease, and probably immunity be present as well, is shown by the case of a man who had been paralyzed thirty years before and whose serum still protected a monkey from the virus. Since there is no essential difference, except in degree, between the "Netter and Levaditi, Compt. rend. Soc. de biol., 1910, Ixviii, 617. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 79 severe and abortive cases, a description of the symptomatology of the abortive type as a chnically separate group seems unnecessary. Wickman has attempted to classify the various forms of the abor- tive type, and groups them under four headings, thus : 1. Cases which run the course of a general infection. 2. Cases in which meningeal irritation is especially marked (meningism-like ) . 3. Cases in which pain is very marked (influenza-like). 4. Cases with gastro-intestinal disturbance. Such a classification, based purely on symptoms, is perhaps as good as any other, but it is a grouping into which all cases of the disease can well be put during the time when diagnosis is especially diffi- cult and really important. Actually there is little difference between the symptoms of the abortive cases and the prodromal symptoms of cases which become paralyzed, so that in solving the problem of diagnosis during the preparalytic stage, the possibility of recognition of the abortive case will be coincidently accomplished. Our experience with cases which did not develop paralysis has been small numerically. Certain significant points, however, con- cerning the unparalyzed group have come to our notice. There seems to be in many cases some degree of muscular weakness. This may be transient. Two of our cases showed some indefinite weak- ness about the pelvis which made it difficult for the children to stand. They appeared to buckle at the hips and fall, following a sudden change of position or balance (case 32, page 180). Such cases belong perhaps more properly to Miiller's group of " embryo " forms and serve, therefore, to emphasize the number of grades of severity that shade almost imperceptibly one into the other. The record of an abortive case (case 33, page 181) is given completely because the patient was under observation continuously from within twenty- four hours of the first symptom throughout the whole course of the disease. History of exposure, clinical picture, blood and spinal fluid examinations, and finally neutralization of virus M.A., all supported the diagnosis of poliomyelitis without paralysis. In this instance diagnosis of acute poliomyelitis without paralysis was fairly justified. Besides the history of exposure, the spinal fluid showed changes that were most suggestive. Furthermore, the clin- Digitized by Microsoft® 80 A Clinical Study of Acute Poliomyelitis. ical picture was very striking, apathy and drowsiness being most obvious. However, it is difficult to select any one feature of the case as pathognomonic; a history of exposure is in itself extremely unreliable evidence. The following example is illustrative of this fact. Donald P., aged three years, suffered from malaise, anorexia, and drowsiness a day or two before his brother fell sick with a fatal attack of poliomyelitis, but his blood serum failed to neutralize the virus. While this is perhaps not absolute proof, still it should make one a little less ready to diagnose abortive poliomyelitis in every child who is a little indisposed in the summer. Two other examples of the abortive type that came to our notice were interesting be- cause of the very slight muscular weakness that each displayed. If it had not been for the history of exposure, it is quite possible that both of these cases would have been overlooked. The weak- ness was so slight and consequently so difficult to locate, and above all so transient, that it very nearly escaped observation. Of the other clinical features, it may be said that irritability and drowsiness are frequently present. The knee jerks are most vari- able. Wickman reports instances of disappearance of the reflex on one or both sides, and also cases where the reflex is exaggerated. Pain is a very common symptom, just as it is in the paralyzed cases. The pain, as described in the section on the acute stage, may be muscular or neuritic, often in the neck or back, or in the form of headache. The disease which, perhaps, the abortive cases most frequently resemble is influenza. Consequently, such cases occurring during the summer months, especially in the neighbor- hood of a patient with paralysis, should be viewed with suspicion and quarantined. THE BLOOD. The complete symptomatology of filterable virus diseases in man is not yet established. Certain clinical features of the two examples most studied, hydrophobia and poliomyelitis, have been well de- scribed, but the blood picture, which has been so thoroughly deter- mined in most infectious diseases and is of such value in differential diagnosis, is little discussed. Owing to the resemblance of numer- ous features of rabies and poliomyelitis, it seemed that a compara- tive study of the blood changes in the two diseases might throw Digitized by Microsoft® Francis W. Peahody, George Draper, and A. R. Dochez. 81 some further light on the nature of the human body's reaction to invasion by infecting agents of this type. Unfortunately, however, despite the great amount of information that has been recorded about each of these diseases, only a few meagre and often con- flicting statements are to be found on the subject of blood. The Systems of Medicine make no mention of blood counts in either malady. In one exhaustive report of thirty cases of rabies by Bain and Maloney^' the blood of one case is reported to have had a "slight polymorphonuclear leukocytosis." Through the courtesy of the attending physicians at the Presby- terian Hospital, New York, the following blood counts from cases of hydrophobia are available : Patient 1. Male, age 35 years. Temperature 99.3° F. Per Per cent. cent. Polymorphonuclears ... 76.0 Transitionals .... 3.8 Leukocyte count 9,400. Lymphocytes lO.S Basophiles 0.0 Large mononuclears. . . 9.8 Eosinophiles 0.0 Patient II. Male, age 27 years. Temperature 100-103° F- Per Per cent. cent. Polymorphonuclears . . . 76.5 Transitionals 2.5 Leukocyte count 13,000. Lymphocytes il.o Basophiles 0.0 Large mononuclears. . . lo.o Eosinophiles 0.0 Patient III. Male, age 27 years. Temperature 103° F. (Nov. 26.) Per Per cent. cent. Polymorphonuclears .. 85.0 Transitionals 3.0 Leukocyte count 34,450. Lymphocytes 12.0 Basophiles 0.0 Large mononuclears... 0.0 Eosinophiles 0.0 Patient III. Temperature 103° F. (Nov. 27.) Per Per cent. cent. Polymorphonuclears . . 87.0 Transitionals .... 2.0 Leukocyte count 30,200. Lymphocytes lo.S Basophiles 0.0 Large mononuclears.. . O.S Eosinophiles 0.0 " Bain and Maloney, Lancet, 1909, ii, 772. Digitized by Microsoft® 82 A Clinical Study of Acute Poliomyelitis, Obviously, except in the first case where the total count was nor- mal, there was a leukocytosis. In all the cases a definite polymor- phonucleosis existed with a low lymphocyte percentage. In the literature of poliomyelitis there are conflicting statements about the leukocyte count. La Fetra,*" in New York, and Miiller, in Germany, have made the most extensive observations on the blood. The former reported in six cases a leukocytosis, running from 13,400 to 20,600. He says nothing about the differential counts. Miiller, on the other hand, reporting fifteen cases, says that a leukopenia of from 3,000 to 5,000 was always present in the acute stage. He gives no figures but states that there was a slight in- crease of the lymphocytes. Gay and Lucas made a comparative study of the blood in monkeys suffering from the experimentally produced disease, and of children with poliomyelitis. In monkeys they report a leukopenia during the acute stage with a lympho- cytosis ranging from 10 to 20 per cent, above normal. The proto- cols of the human cases, however, do not support very convincingly their statements that a similar blood picture occurs in the human cases. The lowest count, that reported from a nine months' old baby, (case II) is 7,800 to 12,200. The other three cases showed the following leukocyte counts : Case I, 20 months, 11,600-17,400. Case III, 2 years, 12,000. Case IV, 5 years, 13,400. These can hardly be considered leukopenias. In two of their four cases, a lymphocytosis, "slight" for one, and "62 per cent." for the other, is given. Of the other two cases, one, a child of five years, had a normal differential count, and the other a polymorphonuclear cytosis of 75.5 per cent. The following tables and the ensuing statements are based upon the study of the blood of our seventy-one hospital patients. The actual figures given represent the counts from only fifty-nine cases. The records of the other twelve cases were omitted because those patients suffered from other conditions which might have affected the blood count. Care was taken to avoid collecting the blood at " La Fetra, loc. cit. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. DocJiez. 83 times when a digestive leukocytosis might have been present. The total white count was made in the usual way, the blood and 0.5 per cent, acetic acid solution being mixed in a i :io pipette and the drop counted on a o.i of a millimeter cell. For differential counts, Wright's modification of the Romanowski stain was used. The first series of tables has been arranged simply to record the counts by weeks of the disease and age of patients. The second series is designed to show minimal, maximal, and average counts .for groups of cases. The composite table (page 95) shows minimal, maximal, and average total leukocyte counts of all ages together by weeks. Such a compilation seems justifiable, because the age variation is much less in respect to the total than the differential leukocyte count. SERIES I. Age 6 to 12 Months. First week. Number of case. Total leukocyte ; Polymor- count. phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. philes. Eosino- philes. Stimula- tion forms.f I* 25,300 I 35.600 f 23.900 5 23,800 59-0 32-0 25-0 65.0 23-S 55-5 57-0 16.5 2-S I.O 2.0 18.0 I3-S 9.0 15.0 o.S 0-5 0.0 0.0 0.0 0.0 1.0 1.0 0.0 1.0 1-5 i-S 0.0 Age 1 to 2 Years. First Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- of case. count. phonuclears. cytes. nuclears. tionals. philes- philes. tion forms. I J IS.300 36.0 50.0 2.0 7-S 0.0 S-5 0.0 2 •^ 16,300 26.5 42.0 7-S 13-S 1.0 9-S o.b 3 i 15,000 52.5 3I.S I3-S I-S 0-S o.S 0.0 4 f 15,200 44.0 33-S 12.S 6.0 0-0 3-0 1-0 8 i 15.700 53.S 28.S 12.S 4-5 I-O 0.0 0.0 9 i 26,000 27.0 39-0 lO.O 8.0 0-0 iS-S 0.5 10 t 18,200 Si.S 29.0 2.0 9.0 0.5 8-0 0-0 12 f 23,300 70.0 16.5 30 9-0 0.5 O-S 1.0 14 i 17.SOO 42.5 47.0 i-S S-O 0.0 3-5 O.S 17 * 12,200 47.0 40.0 lO.O 2-S 0.0 0.5 0.0 18 i 17,100 38.0 49.0 I-S II. 0.0 0.0 0.5 , 20 i 13,400 67.S 28.0 7-0 S-o 0.0 2.0 0-5 * The numerator of the fraction signifies the day of disease, the denominator the day of paralysis. t " Stimulation forms " of Turck. Digitized by Microsoft® 84 A Clinical Study of Acute Poliomyelitis. SERIES I (continued). Age I to 2 Years. Second Week. Kumber of case. Total leukocyte count. Polymor- phonuclears- Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms 5 W 14,800 44.0 56.0 — — — 6 -\- 14,200 43-5 42.0 7-5 6.5 0.0 O.S 0.0 8 y| 22,000 46.0 38.S 0-5 II. 0.5 3-S 0.0 10 jf 30,400 73-5 9.0 8.5 7.0 6.0 2.0 0.0 II j§ 12,300 37.0 56-0 I.O 4.0 0.5 1.0 O.S 13 f 16,000 45-5 2I.S 23.0 6.0 2-5 1.0 0.0 14 \^ 16,100 47.0 38.0 1.0 7.0 1.0 s-s O.S • 15 f 16,200 Si-o 30.5 9.0 50 4-S 0.0 0.0 17 ^1 17,400 64.0 23.0 o.S 8.0 2.0 2.0 0.5 19 1 20,000 45-0 40. s 0.0 9-5 1.0 35 0-5 20 \^ 16,200 53-5 3I-S 4-S 10. 0.0 0.0 0-5 Third Week. Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms I jf 14,600 47.0 43-0 4.0 2.0 0.0 3-5 O.S 1 rf 17.600 41.0 38.S 3-0 4.0 0.0 lo.s 2.S 4 Tj 14,800 430 39S i-S 13-5 1.0 i.S 0.0 S •jf 8,300 61.S 30.5 50 0-5 0.0 4.0 0.5 6 yj 19,100 50.0 40.S 2.0 6.S 0-5 o.S 0.0 7 Jj4 12,200 67.0 22.0 7-5 2.S O.S 0.0 O.S 8 rf 15.900 50.0 350 4-0, 8.S o.S IS O.S 9 y| 26,100 30.S S8-S 30 S-S 0.0 2.S 0.0 13 tI 38.4 SS-2 5-6 0.4 0.0 0.0 0.4 IS yf 22,500 64- s 29-5 30 1-5 1-5 2.0 0.0 16 f 13.400 42.0 43-5 1.0 lO.O 1.0 2.S 1.0 ' 18 \\ 17,200 49-5 39-0 6.5 3-S 0.0 1.0 O.S I9 yf 25,600 S9-0 33-5 0.0 7-S 0.0 0.0 0.0 Fourth Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. I H 13.500 33.0 44-0 9S 9.0 0.0 4.0 0.5 4 yf 20,100 33-0 52-5 3.S 7-5 0.0 2.0 I-S S \\ 17,800 60.0 34-5 30 1-5 0.0 1.0 0.0 6 \% 24,700 55-5 38.0 S-S 2.0 0.0 I-S 0.0 7 f4 10,100 41.0 50.0 6.0 2.0 O.S 0.0 0.5 II fl 15,800 42.0 37-0 4.0 17-5 1.0 1.0 2.5 13 fy 16,000 29.0 63-S 4-5 i-S 0.0 I.S 0.0 14 |y 18,400 340 52.0 7-0 S-S 0.0 I.S 0.0 15 If 21,500 46.S 28.0 22.0 3-5 0.0 0.0 0.0 16 W 14,200 26.5 23.0 44.0 3-S 0.0 2.5 0.0 19 If 15,200 51.0 21.5 20.5 3-S 1.0 2.5 0.0 Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Bodies. 85 SEMES I (continued). Age I to z Years. Fifth Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- . of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. I f 5 20,300 60. s 20.S lO.O 2.0 o.S 6.0 O.S 2 fj- 23,600 42.S 26.0 I3S 10.0 0.0 6..5 1.0 4 It 9,100 40.0 42.0 7-5 7-S 0.0 2-5 o.S 6 ^7 21,600 38.0 56.0 I.O 3-S 0.0 2.0 0.0 7 TT 13.100 38.5 43-7 8.0 8.S 0.0 2.0 0.0 8 If 16,400 43-0 42.0 8.0 3-S 0.0 2.S o.S Sixth Week. ■Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- pbiles. Stimula- tion forms. 4 7 II i% 12,600 fj 9,600 If 26,700 37-S 40.0 23.0 49.0 32.0 69.0 0.0 lO.O 6.0 9-S iS-o o.S O.S o.S 0.0 2.S O.S i-S 1.0 2.0 0.0 Seventh Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms^ 8 II ff 26,700 II 23,700 Si-o 3I-S 34-5 4S-0 lO.O 9.0 4.0 S-0 0.0 2.0 O.S 6-S 0.0 0.5 Age 2 to 3 Years. First Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- .of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. I 4 1S.300 S6.0 30.S 8.S 3-0 I-S O.S 0.0 2 f 23,000 56.0 20.0 lo.s 12.0 0-S o-S O.S 3 18,400 32.S 430 14.0 9-S 0.0 0-S 0.0 II 13.800 47-S 31-0 i-S 7.0 0-5 7-0 1.0 12 f 9.S00 64.5 2I.S 7.0 3-S 1.0 1.0 I-S 14 1 14,200 S8.S 3I.S 7.0 3-0 0.0 0.0 0.0 IS • 10,600 49.0 28.0 2.0 18.0 o.S 2.0 o.S Second Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. S -i 16,400 38.0 41.0 S-0 10.5 0-5 4-S 0-S 6 J^ 15,900 60.0 lO.O 23s S-S 0.0 1.0 0.0 7 f 9,800 61.S 21-5 2.0 7.0 0.0 7-S 0-S 9 1 20,000 S7-0 23-S 8.S 4-S 0.0 6-S 0.0 10 f 12,400 S4-0 28.0 7.0 S-0 0.0 S-0 0.0 II ^f 15,200 47-6 31-3 14.0 2.0 0.0 0-S 0.0 13 1 16,600 S3-0 340 4.0 3-S S-0 0.0 O.S 14 XT 11,200 S2-0 3S-S 7-5 3-0 0-S I-S 0.0 Digitized by Microsoft® 86 A Clinical Study of Acute Poliomyelitis. SERIES I (continued). Age 2 to 3 Years. Third Week. Number of case. Total leukocyte count. I*olynior- phonuclears. Lyjnplio- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 S 6 8 IS \i 23,700 \\ 13,600 1 12,800 1 14,100 jf 18,700 63-5 45-0 55-0 52.0 47-5 24-5 42-5 16.0 27-S 35-S 0.0 5-0 24-5 14-5 7.0 9-S 6.0 2.5 2.5 7.0 0.0 0.0 o.S 0.0 0.0 2.0 I.O i-S 2.5 30 0.5 0.5 0.0 0.5 0.0 Fourth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 6 8 10 II f^ 23,600 If 18,800 If 14,600 II 19,800 II 23,000 65.0 43.5 26.S 61.0 57-0 23.0 46.0 50.0 23-5 32.0 4.0 O.S 10.5 95 0.0 7.0 lO.O 7.0 4-5 7-5 0.0 0.0 0.0 0.5 0.0 1.0 0.0 6.0 O.S 30 0.0 0.0 0.0 0.0 0.0 Fifth Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. 4 1^ 19.400 46.0 33-5 4.5 6.0 0.0 9-5 O.S 6 M 21,700 57-5 36.0 2.0 5-0 0.0 2.S 0.0 7 M 16,400 40.0 38.5 95 14.0 0.0 8.0 0.0 8 11 15,000 43-0 44-5 5-0 3-5 0.0 3.5 0.0 9 II 18,100 58.0 21.5 5-5 ii-S 0.0 3.5 0.0 II 1 J 27,000 46.0 41.0 0.0 SO 0.0 7-5 0.0 Sixth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympbo- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 6 9 If 22,800 If 14,800 If 10,200 57-0 Si-S 4S.0 29.0 44.0 39.0 4-5 30 2.0 4-5 0.5 9.0 0.5 0.0 0.0 2-5 0.5 3-5 2.0 O.S 1.0 Seventh Week. Number of case. TotaHeukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- phils. Eosino- philes. Stimula- tion forms. 4 6 9 IJ 15.800 Jf 22,300 If 16,800 70.0 42.5 SI-S 16.0 43-6 2S-S 9-5 O-S II. 3.5 7-5 6.5 0.0 O.S O-S 1.0 1.0 S-o 0.0 0.0 0.0 Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 87 SERrES I (continued). Age 3 to 4 Years. First Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- Stimula- or case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. f { 6,900 ll 8,300 56.5 29.0 — 130 0.5 0.0 1.0 72.0 2I.S I.O 50 0.0 0.0 o.S 2 f 15.400 63.0 17.0 SO 8.5 0.0 6.0 0.5 3 f 10,100 61.0 26.5 6.S 5-0 0.0 0.5 0.5 4 i 15,100 55-0 26.0 8.S 1.5 0.0 9.0 0.0 Second Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 5 f§ 14,600 j-f 19,700 S7-S 84.0 2I.S 6.S 13-5 6.5 6.5 3-0 0.0 0.0 0.5 0.0 0.5 0.0 Third Week. Number of case. Total leukocyte count. Polymor.- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- pbiles. Stimula- tion forms. I 4 ^^ 10,300 tI is. 700 59-5 45-0 20.0 37-S 6.S 2.0 14.0 S-5 0.0 1.0 0.5 6.5 0.0 Fourth Week. Number of'case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 5 11 19,800 ft 11,000 51-0 40.5 37-5 46.S 0.0 1-5 3-5 8.5 0.0 0.5 8.0 2.0 0.0 0.5 Fifth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 4 . S II 12,800 M 16,700 II 15,000 54-0 SS-o 60.5 30.0 30.0 25-0 6.0 10.5 6.5 6.S 2.5 30 0.0 0.0 1.0 2-5 2.0 4.0 0.5 0.0 0.0 Seventh Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I If 9,800 49-5 30.S 4.0 II-S 0.5 4.0 0.0 Digitized by Microsoft® 88 A Clinical Study of Acute Poliomyelitis. SERIES I (continued). Age 4 to 5 Years. First Week. Number Total leukocyte Polymor- Lympho- Large mono- Transi- Baso- Eosino- of case. count. phonuclears. cytes. nuclears. tionals. philes. philes. tion forms. I 1 33.000 — — 4 1 19.300 73-0 18.6 2.6 4.6 0.0 0.0 0.6 S f 17,600 44- S 37-5 30 14-5 0.0 0.0 0-5 6 f 20,000 49.0 25-0 26.5 8.0 1-5 0.0 0.0 7 1 13.000 Si-S 370 7.0 4-5 0.0 0.0 0.0 8 J 12,400 53-0 24.0 9-S 12.0 0.0 0.0 0.0 Second Week. Number of case. Total leukocyte count. Polymor- phonuclears, Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. xf 28,000 Third Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Easo- philes. Eosino- philes. Stimula- tion forms. 3 If 20,800 — — — Fourth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 2 3 II 10,500 |j 12,000 ft 22,300 SS-O 58.S 42.0 30.0 27.9 33.8 lo.s 9.0 6.4 4.0 2.0 2.1 0.0 0.0 0.6 0.5 3-S 2.7 0.0 0.0 0.3 Fifth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Easo- philcs. Eosino- philes. Stimula- tion forms. 2 3 ffj 14,800 lit 6,300 II 20,000 85.0 62.5 65.0 19.0 24.0 12.0 o.S 3-5 7.0 I.O 0.0 2.0 2.0 0.0 1.0 Sixth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 3 IJ 13,100 If 28,600 64.0 57.S 23.S 34.0 8.S 7.0 30 i-S 0.0 0.0 1.0 0.0 0.0 0.0 Seventh Week. Number of case. Total leukocyte count. Polymor- phonuclears. If 12,400 If 11,000 39.S 62.0 Lympho- cytes. 54-5 16.0 Large mono- nuclears. o-S 10.5 Transi- tionals. 4.0 0.5 philes. 0.5 9.5 Eosino- philes. 0.5 1.0 Stimula- tion forms. 0.5 0.5 Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 89 SERIES I (continued). Age 4 to 5 Years. Eighth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 1 2 fl 12,000 §J 10,700 47.0 52.S 37.S 35.5 8.5 9.0 S-S 2.5 0.0 0.0 1.5 0.5 0.0 0.0 Tenth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I If 10,800 61.S 23.5 4-S 9.0 0.0 0.0 0.5 Twelfth Week. Number ot case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I If l6,000 54-0 38.0 5-5 2.0 0.0 i.S 0.0 Age 5 to 7 Years. First Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 2 3 4 i 19.400 f 23,200 1 8,8oo 1 20,800 62.2 76.0 77.0 66.0 16.7 17.0 I7-S 24.0 II.7 3.0 o.S I.O 1.0 2-5 4.0 S-S 0.2 1.0 0.0 1.5 8.0 0.0 0.0 2.0 0.0 0.5 1.0 0.0 Second Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- pbiles. Eosino- philes. Stimula- tion forms. 3 y- ii,8oo 76.S 14-5 4-5 3-S 0.0 0.5 O.S Third Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 fl 28,800 72.0 9.0 2.0 lO.O 0.0 2.0 0.0 Fourth Week. Number of case. Total leukocyte count. Polymor- phonuclears Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I 2 If 14,200 ^f 21,100 49.5 64-5 36.0 25.0 I2-S 2.5 0.0 0.5 0.0 0.0 0.0 0.0 Digitized by Microsoft® 90 A Clinical Study of Acute Poliomyelitis. SERIES I (concluded) . Age 5 to 7 Years. Sixth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- phUes. Eosino- philes. Stimula- tion forms. I H 15.600 50.0 32.5 4.0 II.O 0.0 I.S I.O Seventh Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I ^t l6,000 59-5 22.0 7-5 8.5 O-S 2.0 0.0 Age 8 to 12 Years. First Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 2 3 4* I 16,700 1 12,000 f 13,000 750 7S.0 59-0 150 130 17-5 O-S 3-S 17.0 9-5 8.0 4.5 0.0 0.0 O-S 0.0 1.0 I.S 0.0 0.0 0.0 Second Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- .cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philos. Stimula- tion forms. 4 If 12,000 62.0 17-5 16.0 3-S 0.0 1.0 0.0 Third Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino^ philes. Stimula- tion forms. I 4 \\ 7.800 fl 18,000 63.0 67-S 28.0 19-5 4-5 3-S 2.0 9.0 0.0 0.0 2.S 1.0 0.0 0.0 Fourth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- pbiles. Eosino- philes. Stimula- tion forms. I 4 i\ 9.400 1^ 10,700 64-S 62.S 26.0 26.0 0.0 2-S 4-S 8.0 o.S 0.0 4.S O.S 0.0 O.S Sixth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. I II 9.400 47.0 37-5 5-5 4.0 1 0.0 3.5 2.5 Eighth Week. Number of case. Total leukocyte count. Polymor- phonuclears. Lympho- cytes. Large mono- nuclears. Transi- tionals. Baso- philes. Eosino- philes. Stimula- tion forms. 4 i§ 16,000 58-0 32.5 1.0 6.0 0.0 2.0 O.S * Age, 21 years. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. 91 SERIES 11. First Week. Q li 2gg ^3" , id s-,.a IS B a ^ lii ►J 1" H-3 4 23,900-35.600 f Maximum sg.o \ Minimum 25.0 \ Average 42.0 57-0 16.5 36.7 18.0 I.O 9-5 150 0.5 7-7 0.5 0.0 1.0 0.0 0.0 12 12,200-26,000 Maximum 70.0 Minimum 26.5 ^ Average 48.2 iJO.O 16.5 33-2 13-5 i-S 7.5 13-5 2-5 8.0 1.0 0.0 1S.5 0.0 1.0 0.0 s 9,000-23,000 f Maximum 64.5 ■j Minimum 32.5 [ Average 48.5 43-0 20.0 3I-S 14.0 7.7 18.0 3-0 10.5 1-5 0.0 7.0 0.0 1-5 0.0 4 6,900-15,000 f Maximum 72.0 Minimum 55.0 [ Average 68.5 29.0 17.0 23.0 8.5 1.0 4-7 13-0 1-5 7:2 0.5 0.0 9.0 0.0 1.0 0.0 6 12,400-33,000 f Maximum 81.0 ■ Minimum 44.5 [ Average 62.7 37-5 18.6 28.0 26.S 2.6 14-5 14-5 4.5 9-5 1-5 0.0 0.0 0.0 0.5 0.0 4 8,800-23,300 Maximum 77.0 Minimum 62.2 Average 69.6 24.0 16.7 20.3 11.7 0.5 6.5 5-5 1.0 3-2 1.0 0.0 8.0 0.0 1.0 0.0 3 38 12,000-16,700 ' Maximum 75.0 Minimum 59.0 Average 67.0 17-5 13.0 15-2 17.0 0.5 8.7 9-5 4-5 7.0 0.05 0.0 1-5 0.0 0.0 0.0 Second Week. 111 I- A C3 S It ll II 12,300-30,400 Maximum 73.0 ■ Minimum 37.0 Average 55.0 56.0 9.0 32.5 23.0 0.5 11.7 II.O 4.0 7-7 6.0 0.0 5-5 0.0 0.05 0.0 8 9,800-20,000 Maximum 61.5 Minimum 38.0 Average 49-7 41.0 lO.O 25-5 23-5 2.0 12.7 10.5 2.0 6.2 5.0 0.0 7-5 0.0 0.5 0.0 2 14,600-19,700 ■ Maximum 84.0 Minimum 57.5 Average 70.7 21.5 6.5 14.0 13-5 6.5 lO.O 6.5 3-0 4-7 0.0 0.0 0.5 0.0 0.5 0.0 I 28,000 I 11,800 76.5 14-5 4-5 3-S 0.0 0.5 0.5 I 12,000 62.0 17.5 16.0 3-5 0.0 1.0 0.0 24 Digitized by Microsoft® 92 A Clinical Study of Acute Poliomyelitis. SERIES II (continued). Third Week. 6 u IP 6 S II S u M 0. cd S ■=0 -13 a to .2 f Maximum 67.0 58.5 7-5 I3-S i-S 10.5 1.0 1-2 yrs. 13 8,300-26,100 Minimum 30.5 [Average 48.7 22.0 40.2 0.0 3-7 o.S 7.0 0.0 0.0 0.0 Maximum 63.5 42.5 24-S 95 0-5 30 0.5 2-3 yrs. S 12,800-23,700 \ Minimum 45.0 Average S4-7 16.0 29.2 0.0 12.2 2.S 6.0 0.0 1.0 0.0 { Maximum 39.5 37-S 6.S 14.0 I.O 6.S 0.0 3-4 yrs. 2 10,300-15,700 \ Minimum 45.0 [ Average 52.2 20.0 28.7 2.0 4.2 5-S 9-7 0.0 o.S 0.0 4-5 yrs. I 28,000 S-7 yrs. I 28,000 72.0 9.0 2.0 lO.O 0.0 2.0 0.0 f Maximum 67.5 28.0 4-5 9.0 0.0 2.5 0.0 8-12 yrs. 2 7,800-18,000 \ Minimum 63.0 [ Average 65.2 19-5 23-7 35 4.0 2.0 0.0 1.0 0.0 Total 24 Fourth Week. < Is S S 3 Hi 6 ■as H-l 6 " at = 6 n It .5 P "3 1-2 yrs. 11 10,100-24,700 f Maximum 60.0 Minimum 26.5 [ Average 43.2 63.5 21.5 42.S 41.0 35.0 23-7 17.0 I-S 9-5 1.0 0.0 4.0 0.0 2-5 0.0 2-3 yrs. S 14,600-23,600 r Maximum 65.0 • Minimum 26.5 [Average 45.7 46.0 23.5 34-7 lO.S 0-5 S-5 10.0 4-5 7.2 o.S 0.0 6.0 0.0 0.0 0.0 3-4 yrs. 2 11,000-19,800 r Maximum 51.0 ■ Minimum 40.5 [Average 45.7 46.5 37-5 42.0 i-S 0.0 0.7 8.5 3-5 6.0 0.5 0.0 8.0 2.0 o.S 0.0 4-5 yrs. 3 10,500-22,300 f Maximum 58.5 ■ Minimum 42.0 [ Average 50.2 33.8 27.9 30.8 10.5 6.4 8.4 4.0 2.0 3.0 0.6 0.0 2.7 0.5 0.3 0.0 5-7 yrs. 2 14,200-21,000 f Maximum 64.5 ■ Minimum 49.5 [Average 57.0 36.0 25.0 30.0 12.S 7-5 lO.O 2.5 I-S 2.0 0-5 0.0 0.0 0.0 0.0 0.0 8-12 yrs. 2 9,400-10,700 f Maximum 64.5 Minimum 62.5 , Average 63.5 26.0 2.5 0.0 1-7 8.0 4-5 6.2 o.S 0.0 4-5 o.S o.S 0.0 Total 25 Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. SERIES II (continued). Fifth Week. 93 1 a . ■S.S ii II M "1 is Maximum 60.5 S6.o 13-5 10. 0.5 6.S 1.0 -2 yrs. 6 9,100-23,600 \ Minimum 38.0 [ Average 49.2 20.S 38.2 I.O 7.2 2.0 6.0 0.0 i-S 0.0 f Maximum 58.0 44-5 9S 14.0 0.0 9-5 o-S -3 yrs. 6 IS.000-27,000 \ Minimum 40.0 [ Average 49.0 21.S 330 0.0 4.2 50 9-S 0.0 3-S 0.0 Maximum 60.5 30.0 10.5 6.S 1.0 4.0 o.S -4 yrs. 3 12,800-16,700 Minimum 54.5 Average 57.5 25.0 27-S 6.0 8.2 2.5 4-5 0.0 2.0 0.0 f Maximum 85.0 24.0 12.0 7.0 1.0 2.0 1.0 -s yrs. 2 6,300-20,000 \ Minimum 62.5 [ Average 73.7 19.0 2I-S 0.5 6.2 3-S 5-2 0.0 0.0 Total 17 Sixth Week. i < H si 1 2 . E a ii Large mononu- clears. Ii id It -2 yrs. 3 9,600-26,700 Maximum 40.0 Minimum 23.0 Average 31.5 69.0 32.0 50.5 10. 0.0 5-0 150 0.5 7-7 0.5 0.0 2.5 0.5 2.0 0.0 -3 yrs. 2 10,200-22,800 f Maximum 57.0 Minimum 45.0 [ Average 51.0 44.0 29.0 36.5 4-5 2.0 3-2 9.0 0.5 4.7 0.5 0.0 3-S o-S 2.0 O-S -5 yrs. 2 13,100-28,600 f Maximum 64.0 \ Minimum 57.5 [ Average 60.7 34-0 235 28.7 8.5 7.0 7-7 30 i-S 2.2 0.0 0.0 1.0 0.0 0.0 0.0 -7 yrs. I 15,000 50.0 32-5 4.0 II.O 0.0 1-5 1.0 -12 yrs. I 9,400 47.0 37-S 5-5 4.0 0.0 3-5 2.S Total 9 Digitized by Microsoft® 94 A Clinical Study of Acute Poliomyelitis. SERIES II (concluded). Seventh Week. 1 li 2; lis O O 3 , E ^11 i ■§,3 ^1 in 4 •3 Maximum 51.0 4S-0 lO.O 5-0 2.0 6.5 0-5 1-2 yrs. 2 23,700-26,700 ■ Minimum 31.5 Average 41.2 34-S 39-7 9-5 9-7 4.0 0.0 o.S 0.0 f Maximum 70.0 43-6 II. 7-5 0.5 S.o 0.0 2-3 yrs. 3 15,800-22,300 ■ Minimum 42.5 [ Average 56.2 16.0 29.8 0.5 S-7 3.5 5-S 0.0 I.O 0.0 3-4 yrs. I 9,800 49.0 30.S 4.0 ii-S O.S 4.0 0.0 { Maximum 62.0 S4-S lO.S 4.0 9-5 1.0 0-5 4-S yrs. 2 11,000-12,400 \ Minimum 39.5 [Average 50.7 16.0 35-2 0.5 5-S o.S 2.2 0.5 o.S 5-7 yrs. I 16,000 59-5 22.0 7-S 8.5 o.S 2.0 0.0 Total 9 Eighth Week. 1 2; tt) _4i. III 6 2 si .1= en .2 { Maximum 52.5 37-5 9.0 s-s 0.0 i.S 0.0 4-S yrs. 2 10,700-12,000 Minimum 47.0 [Average 49.7 3S-S 36.S 8.5 8.7 2.S 4.0 0.0 O.S 8-12 yrs. I 16,000 58.0 3Z.S 1.0 6.0 0.0 2.0 O.S Total 3 Tenth Week. 4-S yrs. IS iz; 2 frc O O 3 H 3 S 10,800 O I.— 0. 2 ^ 61.S E?, 23-S c3 c u 4-S H-a 9.0 m1 Twelfth Week. 9 s •s fl U3.2 0.5 4-S yrs. ES "so 16,000 S4-0 ES, 38.0 C4 B oj J £13 S-S W3 I.S in .2 0.0 Digitized by Microsoft® Francis W. Feabody, George Draper, and A. B. Dochez. 95 ALL AGES. Number of cases. Leukocyte count. Maximum. Minimum. Average. 1st week 38 24,600 12,200 18,400 zd week 24 24.500 12,000 18,250 3d week 24 23,300 10,400 16,800 4th week 25 20,300 11,600 15.900 Sth week 17 21,800 10.800 16.300 6th week 9 23,200 10.500 16.800 7th week 9 19.500 IS.OOO 17,250 Sth week 3 14.000 10,700 12,400 loth week I 10,800 12th week I 16,000 Total ISI The following table comprises separately the counts from pre- paralytic and abortive cases. 1 . 2 Ifl 5 a 1" ■a » II .ii ll *< a mo Breed's case 15,000 — — — — 1 7,000 81.0 — — — — J. s 2i yrs. i 14,200 58.S 31-5 7.0 30 0.0 0.0 0.0 C. T 8 mos. % 35.600 32.0 55-0 I.O 9.0 0.0 1.0 1-5 E. N 6 yrs. § 23,200 76.0 17.0 3-0 2.5 0.0 1.0 0.5 H. B 6 yrs. f 8,800 77.0 17-5 0.5 4.0 0.0 0.0 1.0 1 11,200 79-5 14-5 0.5 4.5 0.0 0.5 0.5 1 5,600 68.5 22.0 i-S 6.0 0.0 1.0 1.0 V- 11.800 76.5 14-5 4-5 3-5 0.0 0.5 0.5 P. T 2 yrs. i 15,000 52.5 31-5 135 1-5 o-S 0.5 0.0 It is obvious from these figures that while in most cases in the preparalytic stage the total leukocyte count varies within the normal, there is a tendency toward the upper limits. More cases showed counts well above than below the usual extremes. In the differential counts there is a definite polymorphonucleosis with the one exception of a count in an infant eight months old, where the relation of polymorphonuclears and lymphocytes is normal. Furthermore, the lymphocyte percentages in all the other' cases are distinctly below the usual figure. In one instance where blood counts were made by the physician before the patient came to the hospital, a low total count appeared ; Digitized by Microsoft® 96 A Clinical Study of Acute Poliomyelitis. 7,000, two days before the paralysis, and 3,000 on the day after paralysis. The differential count, however, showed a polymorpho- nuclear increase each time (81 per cent, and 58 per cent.). Except for this one case which subsequently became one of pur seventy-one, we have not seen a true leukopenia. One abortive case in a little girl six years of age showed counts of 5,600 to 11,800. In the youngest children the leukocyte counts have been highest, and the polymorphonuclear increase both relatively and actually has been more marked than in the older patients. A glance at the tables, however, will show that all ages have a high white cell count. Furthermore, the leukocytosis persists for a surprising length of time. In nine cases, for example, observed during the seventh week, the leukocytes numbered 15,000 to 19,500, with an average of 17.250- The differential count presents a fairly constant picture. For comparison, a table of differential counts from normal individuals prepared by Schloss*^ is printed. There is obviously in poliomyelitis an increase in polymorphonuclear cells of 10 to 15 per cent, above the normal. This increase appears irrespective of the patient's age, though the youngest children have shown perhaps the highest poly- morphonuclear counts. Contrary to the observations of Miiller, and Gay and Lucas, we have found a diminution of lymphocytes. In general, they have been from 15 to 20 per cent, below the normal percentages. Notwithstanding the great variation which these cells present in relation to age, the finding of low lymphocyte percentages has been constant in all our cases of poliomyelitis. The transitional and large mononuclear cells have reached no abnormal figures. In many cases there has been an increase in eosinophiles. This finding, however, has not been sufficiently con- stant to justify further comment. No counts were made of the red cells, nor were any hemoglobin estimations recorded. There has been nothing in the appearance of the patients to suggest an anemia resulting from the disease ; nor did the stained erythrocytes look abnormal. No actual counts of the blood platelets were made, but the impression was gained in the course of many differential counts that these elements were somewhat increased. "Schloss, Arch. Int. Med., igio, vi, 638. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 97 DIFFERENTIAL BLOOD COUNTS IN NORMAL INDIVIDUALS. Age. Polymorpho- nuclears. 1 Lympho- cytes. Large mono- nuclears. Eosino- philes. Basophiles. 6-12 mos. Maximum ■ Minimum Average 35-9 24.6 30.4 58.5 S0.5 55-9 12.2 7-3 9.6 4-5 0.0 2.6 0.8 O.I 0.4 1-2 yrs. Maximum ■ Minimum Average 39-7 27-5 36.3 58.8 4S-3 51.2 II. 7 6.7 8.S 6.0 1.6 3.2 0.5 0.0 0.2 2-3 yrs. Maximum ■ Minimum Average 44-3 33.2 38.7 55-0 43-5 49.0 11.3 5.0 8.2 6.0 o.S 3.1 1.2 0.0 0.4 3-4 yrs. Maximum • Minimum Average 54-1 36.2 44-7 47.6 32.2 39-1 16.2 5.0 II. 2 4.2 1.5 2.8 0.9 0.0 0.5 4-S yrs. Maximum Minimum [ Average Si-7 42.2 48.S 49-5 38.4 42.1 6.7 3.4 6.0 4.0 1.6 2.6 0.6 0.3 0.3 S-6 yrs. f Maximum Minimum [ Average 61.8 52.6 S6.S 36.7 21.2 29.9 16.0 6.S lO.O 4.7 0.7 2.S I.O 0.3 0.6 6-7 yrs. C Maximum ■ Minimum [ Average 61.3 52.3 56.0 34-1 24.S 30-4 IS. 7 8.1 10.8 4.7 O.I 2.2 0.6 0.0 0.2 7-8 yrs. r Maximum • Minimum [ Average 72.0 4S.2 54-4 39-1 21. 1 32. 5 15-2 6.7 11.6 3.5 0.0 O.I 0.2 0.0 0.06 To sum up, we have found in the blood of patients with polio- myelitis a constant and marked leukocytosis. In several instances the count has been as high as 30,000. In only one case has there been a definite leukopenia. Besides the increase in the total number of cells, there has been an equally constant increase of polymorpho- nuclears of 10 to 15 per cent., and diminution of lymphocytes of 15 to 20 per cent. The other forms of leukocytes have shown no abnormalities. The recent demonstration of the visceral lesions of poliomyelitis, showing the active part of phagocytosis played by the polymorpho- nuclear cells is perhaps sufficient cause for the polymorphonuclear increase in the circulating blood. In view of the fact, however, that the brunt of the body's attempt at defense falls upon the Digitized by Microsoft® 98 A. Clinical Study of Acute Poliomyelitis. lymphatic system, and that the cells which are assembled at the point of attack seem to be lymphocytes, one might be led at first to expect a lymphocytosis in the blood. On the other hand, the great destruction of lymphocytes, which is evident in the visceral lesions, suggests that these cells are relatively few in the circulation because they are constantly being withdrawn to meet the invasion of the virus at its various points of attack. It will require a more funda- mental knowledge of the kind of reaction the body develops to this type of infecting agent before a correct explanation of the blood picture can be made. At all events, while the blood picture in poliomyelitis is perhaps not any more specific than is the spinal fluid, it is helpful. If taken in connection with other available evidence, a leukocytosis of 15,000 to 30,000 is distinctly suggestive of the disease in question, especially if the polymorphonuclear cells are increased at the expense of the lymphocytes. THE CEREBROSPINAL FLUID. There are two ways in which a careful study of the cerebrospinal fluid in acute poliomyelitis may help to throw light on the disease. On the one hand, the changes observed may facilitate early diagnosis and thus enhance the value of any method of treatment which may be discovered in the future, and, on the other hand, the variations in the character of the fluid, as observed during the progress of the disease in each case, may give some information as to the usual course of the process and thus be an aid in determining how far any given remedy is effective or to what extent the natural course of the disease may be influenced. The following study was thus made with the twofold object of determining whether the examination of the spinal fluid may be an aid in early diagnosis, and what changes occur in the fluid during the course of the disease. Previous investigations along this line have not been extensive. Most writers report only a few cases, and those who have appar- ently made a large number of lumbar punctures have not submitted the fluids to careful examination. The results obtained are some- what variable, but in general the fluid is said to contain an abnormal amount of albumen and a sediment consisting of lymphocytes, large mononuclear cells, and, occasionally, polymorphonuclear cells. Im- Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 99 portant work has been done by Gay and Lucas/^ whose contribu- tions are the most valuable in this field. Their studies have included the spinal fluids from monkeys in the incubation period, the prodro- mal stage, and the acute stage, and from eleven human cases in the preparalytic stage. Besides noting the character of the cells, they have estimated the number of cells per cubic millimeter. In the eleven early cases, the cell count varied from 55 to 580 per cubic millimeter, and the percentage of mononuclears from 75 to 100. Chemical examinations were omitted. Sophian** reports that the globulin test is positive in the early stages. Inasmuch as previous work by Wollstein,** Romer and Joseph,*^ and Gay and Lucas failed to demonstrate the presence of any specific antibody in the spinal fluid in infantile paralysis, we have confined our study to simple chemical and cytological examinations. It has been our object to see the cases as early as possible after the onset of the disease, to make a lumbar puncture on admission to the hospital, to repeat the puncture every two to four days in the early stages, and in the later stages to make a puncture every five to ten days while the case was tinder observation, or until the fluid became normal. We have examined in all 233 fluids from sixty- nine cases. The number of cases seen in the first week of the disease (dating from onset of symptoms, not of paralysis) was forty-three, in the second week, forty-five, in the third week, forty, and in the fourth week, thirty. The number of cases seen later in the course was much smaller. It is to be regretted that the number of preparalytic and abortive cases was so small; of the former, four, and of the latter only two were seen in the active stage. It was, however, rare that cases were referred to the hospital until a positive diagnosis, based on the appearance of paralysis, had been made by the attending physician. The methods used for the examination of the cerebrospinal fluid have included estimation of the pressure, determination of the num- ber of cells per cubic millimeter and the types of cells present, " Gay and Lucas, Arch. Int. Med., 1910, vi, 330 ; Lucas, Am. Jour. Dis. Child., 1911, i, 230. " Sophian, Arch. Pediat., 1911, xxviii, 201. "Wollstein, Jour. Exper. Med., igo8, x, 476. "Romer and Joseph, Munchen. med. Wchnschr., 1910, Ivii, 568. Digitized by Microsoft® 100 A Clinical Study of Acute Poliomyelitis. estimation of the chlorides, and observations of the power of reduc- ing Fehling's solution, and the globulin content. Globulin was tested by the butyric acid method of Noguchi, and the relative strength of the reaction noted. Thus very slightly plus (v. s. +) indicates a faint precipitate, which is, however, definitely more than that obtained with normal spinal fluids; slightly plus (s. + ) is the term applied to reactions giving a well marked cloud or a slightly flocculent precipitate ; plus ( + ) signifies a precipitate coming down in large flocculi ; and double plus ( + + ) , a heavy flocculent pre- cipitate. The reaction was performed with accurately measured amounts of spinal fluid and of reagents, and the reading was made after five to ten minutes' standing. ^^ The gross appearance of the fluids was very constant. Almost all were clear, colorless, and watery. Only a few showed the slightest opalescence. On stand- ing, a delicate web-like clot formed in a small proportion of cases. Clot formation was most frequently seen in the early stages of the •disease. It bore no apparent relation to the globulin content of the fiuid. The results obtained by several of these methods may be dismissed liriefly. Pressiire determinations were made in a number of cases and readings were usually above normal. The pressure was read in millimeters of spinal fluid in a tube of one millimeter bore. No extremely high readings were obtained, and in some instances normal pressures were seen during the early stages of the disease. On the whole, the estimations of pressure were unsatisfactory, as the patients were usually crying children. The chlorides were estimated in a series of cases with the idea that they might throw light on the inorganic substances in the fluid. No marked deviations from the normal were observed. Every fluid examined showed a power of reducing Fehling's solution which was, roughly speaking, normal. This reaction serves as a point of differentiation from many fluids in cases of meningitis, in which the reducing substance may be absent. The type of cell present in the fluid was almost always the " To 0.2 c.c. of spinal fluid is added 0.5 c.c. of butyric acid solution (10 per cent, butyric acid in 0.85 per cent, solution of sodium chloride). The mixture is toiled, o.l c.c. of normal sodium hydrate solution added, and then boiled again. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 101 mononuclear. A large number of differential counts showed that the relative number of the different types of mononuclear cells was of comparatively little importance, so in later observations we were content with noting merely the relative number of mononuclear and pblymorphonuclear cells. In several instances numbers of veiy large phagocytic cells containing vacuoles and broken down cells were seen. Once this occurred several weeks after the onset of the disease in association with a sudden rise in the cell count resembling that seen in acute meningitis. Polymorphonuclear cells, except in small number and probably due for the most part to a slight ad- mixture of blood, were, except in a very few instances, absent after the first week of the disease. Early in the disease, however, and In the preparalytic period, the polymorphonuclears sometimes out-^ numbered the mononuclears and made up 80 to 90 per cent, of the total. The results described by Flexner and Lewis*''' of a study of the cerebrospinal fluid of a monkey after inoculation with the virus of poliomyelitis are interesting. Twenty-four hours after inoculation the fluid contained " a considerable number of small cells, hardly exceeding a lymphocyte in size but showing a polyform nucleus, a few lymphocytes and some red corpuscles. At the expiration of forty-eight hours, the white cells have increased in numbers, but the cells with polyform nuclei still predominate. At the expiration of seventy- two hours, a large number of mononuclear cells have ap^ peared and the fluid presents a striking opalescent appearance. On the day of paralysis the fluid tends to be only slightly cloudy and contains a mixture of large and smaller (lymphoid) mononuclear cells and a few cells with polymorphous nuclei." Lucas, too, found in the monkey during the prodromal stage " a marked increase in the cells, often reaching 1,000 per cubic millimeter. In this stage, ^Iso, polynuclears are still present, in some cases as high as 60 per cent., though the large mononuclears and lymphocytes were very evident. .In the early acute stage the increase in cells is very marked. The cells are now, however, mostly of the lymphocytic or very early form of cells, and sometimes very hard to place, as they are apparently undifferentiated cells." Of his eleven preparalytic "Flexner and Lewis, Jour. Am. Med. Assn., 1910, liv, 1 140. Digitized by Microsoft® 102 A Clinical Study of Acute Poliomyelitis. human cases, however, only one showed less than 87 per cent, of mononuclears, and that had 75 per cent, of mononuclears. A return of polymorphonuclears later in the disease, as was reported by Lucas to occur in monkeys, was not noticeable in our human cases. The cell count was made immediately after the fluid was ob- tained. The first portion of fluid obtained was used, but controls made by comparing counts of early and late portions of the fluid showed no important discrepancy. While the normal number of cells per cubic millimeter of spinal fluid is usually given as 3 to 5, we have considered the upper normal limit as 10 to 12. In general, it may be said that the highest cell counts are found in the early days of the disease, and that there is a progressive falling off as time advances. Thus of forty-three cases in the first week, twenty-three showed fluids with over fifty cells per cubic millimeter, and thirty- eight with cell counts above normal. Two cases showed in the prodromal period 990 and 650 cells respectively. Of forty-five cases in the second week, in eight the counts were over fifty, and in twenty-three cases they were above normal ; of forty cases in the third week in only one was the count over fifty, and in only eight above normal. On the other hand, six cases in the first week, twenty-two cases in the second week, and thirty-two of the forty cases in the third week showed normal counts. In contrast to the cell count which thus tends to be high in the early part of the disease, the globulin content is usually low in the first part of the acute stage, especially as compared with the cell count. It rises during the second and third weeks and then gradually falls, though frequently globulin is present long after all acute symptoms have passed (text-figure 2). M^e have seen a strong -|- globulin reaction on the forty-sixth day of the disease. During the first week, only six of forty-three cases showed at any time a globulin reaction of + (see above) or more. During the second week, twenty out of forty-five cases showed a -f reaction; in the third week sixteen out of forty, and in the fourth week nine out of thirty. On the other hand, sixteen cases in the first week showed an absolutely normal globulin reaction. Five cases in the second week and only three in the third week were negative for globulin. Most cases, even on discharge, gave a globulin reaction which varied from Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 103 slightly to markedly above the normal. In eleven cases the fluids were followed until b6th cell count and globulin reaction became normal. The return to normal occurred in the third week in two cases; in the fourth, in two cases; in the fifth, in one case; in the 750/c Z5% FIRST WEEK SECOND THIRD WEEK FOURTH WEEK 42 5 CASES 45CASI ES 40 CASl ES 3C \t(\SB3 1 \ > \ A w * * " " M ^a ^ " ■ "" • X >< \ \ % > ' \ N. \ % ^ \ / • \ * ^. --. _._ ^ > \ * ^- < /\ \ s. . • \ \ / f . "^ ^^ s; V. V =:. -^ Text-fig. 2. Chart showing variations in cell count and in globulin content of cerebrospinal fluid in infantile paralysis. Percentage of cases with cell count above normal. Percentage of cases with cell count above 50 per c.mm. - - - - Percentage of cases with globulin s. +. ■ — Percentage of cases with globulin + or over. sixth, in two cases ; in the seventh, in three cases ; and in the tenth week, in one case. ' Of the sixty-nine cases studied, only two never showed any ab- normal fluids. In each of these cases the fluids were examined but Digitized by Microsoft® 104 A Clinical Study of Acute Poliomyelitis. once, on the twenty-fifth and thirty-third days of the disease re- spectively. One case showed, in five fluids taken between the ninth and forty-first days of the disease, no evidence of abnormality other than the slightest positive globulin reaction (v. s. +). and another, in three fluids obtained on the ninth, sixteenth, and twenty-third days, gave similar results. Four cases, including one abortive case, showed fluids which, except for the slightest globulin reaction, were normal at the first tapping and subsequently became more definitely positive. The commonest type of fluid seen in the whole series is one with a normal or slightly increased cell count, and a well marked globulin reaction. There are, however, two other distinct types of fluid seen. One is a fluid with a high cell count, and a normal or very slight globulin reaction ; and the other is a fluid with a normal or low cell count, and a very marked globulin reaction. Twenty-six cases showed at some time a globulin reaction of not over s. +, and a cell count of fifty or over. Twenty of these occurred in the first week, and in twelve the count was over loo cells per cubic millimeter. On the other hand, sixty-two fluids from thirty-four cases gave a globulin reaction of + or more. In thirty-three of these the cell count was normal, and in fifty-five it was not above forty per cubic millimeter. That the two types of fluid are fairly distinct is shown by the fact that only five cases showed fluids with both a high cell count (over fifty) and even a moderately high globulin reaction. Each type of fluid is, moreover, quite definitely characteristic of a stage in the disease. The cellular exudate is almost always asso- ciated with the earliest days of the acute stage; the albuminous exudate, with the latter part of the acute stage. It is interesting that of ten cases seen within the first three days after the onset of symptoms, all but one had a cell count of over fifty (one was thirty- seven), and six were over loo. On the other hand, six gave a negative globulin reaction. In four the reaction was s. -f . As regards early diagnosis, the cases examined before the onset of paralysis are of the greatest interest. Six cases were seen in what may be termed the prodromal period. Four of these de- veloped paralysis later and two proved to be of the abortive type. In one case a single lumbar puncture was made on the fourth day Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 10& after the onset. The fluid gave a cell count of 650 per cubic milli- meter, 90 per cent, polynuclears, and a + globulin reaction. Three days later the child suddenly developed paralysis and in five hours died of respiratory failure. A second case, the sister of a child already in the hospital, was seen on the day after the onset of symp- toms. The spinal fluid contained 990 cells per cubic millimeter, 90 per cent, of which were polymorphonuclears, and the globulin reac- tion was s. -f-. On the following day one leg was paralyzed and the cell count of the spinal fluid was 627 per cubic millimeter with 80 per cent, mononuclears. On the next day both legs were paralyzed and the cell count was 1,221 per cubic millimeter with 92 per cent. mononuclears, including many large phagocytic cells. The globulin reaction was -|- (case 34, page 184). Thus two cases seen very early in the course of the disease showed fluids with unusually high cell counts, and with a marked predominance of polymorphonuclear cells. In one of them the change of the cell picture from the poly- nuclear type to the mononuclear type could be followed coincidentally with the onset of the paralysis. Three other cases in the prodromal period, one an abortive case and two becoming paralyzed on the day of the first lumbar puncture, gave cell counts of 37, 94, and 113 per cubic millimeter, with 100 per cent., 93 per cent., and 83 per cent, of mononuclear cells respectively, and globulin reac- tions which fell within normal limits. Finally, in one abortive case lumbar puncture on the second day after the onset of symp- toms gave a wholly normal fluid. On the third day the cell count was sixty-two per cubic millimeter with 89 per cent, mono- nuclears and a s. -j- globulin reaction. On the sixth day the cell' count was fifty-nine per cubic millimeter, all mononuclears, and a globulin reaction of s. +• On the eleventh day the spinal fluid was again normal. That this was, indeed, an abortive case of polio- myelitis was later rendered most probable by a test showing that the patient's blood serum was capable of neutralizing active virus when mixed with it and injected intracranially into a monkey. In these six cases examination of the spinal fluid gave evidence which was helpful in making a diagnosis of poliomyelitis before the onset of paralysis. Similar evidence was afforded by eleven cases of Lucas and by one of Frissell.*^ In none of these twelve cases, "Frissell, Jour. Am. Med. Assn., igii, Ivi, 661. Digitized by Microsoft® 106 A Clinical Study of Acute Poliomyelitis. however, was a large percentage of polynuclear cells found. But it seems of importance to call attention to the fact that a fluid whose cytology resembles that found in cerebrospinal meningitis and other types of purulent meningitis may also occur in the early stages of poliomyelitis. The question arises as to whether there is any relation between the situation and extent of the paralysis or the severity of the disease and the character of the spinal fluid. Conclusions on this point cannot be drawn from the number of cases seen by us. It would seem, however, that in cases in which the paralysis is limited to arms or to cranial nerves, the lumbar puncture fluid is rather apt to show less deviation from the normal than where the legs are involved. This is, however, far from being a constant finding. Several cases which had acute symptoms (pain, irritability) lasting for an unusually prolonged period, gave an unusually large and persistent globulin reaction. Moreover, the disappearance of the acute symptoms was frequently coincident with a diminution in the globulin in the spinal fluid. The fatal cases showed nothing in the fluid on which to base an unfavorable prognosis. Since the infecting organism in poliomyelitis is too small to admit of its being seen, even if it is present in the cerebrospinal fluid, and since the more complicated biological tests have failed to prove the presence of antibodies in the fluid, the diagnostic value of examinations of the spinal fluid by simple chemical and micro- scopic methods must necessarily be merely relative. While in cerebrospinal meningitis, in tuberculous meningitis, in pneumo- coccus, influenza, and similar types of meningitis, one obtains spe- cific information and is usually enabled to make a positive diagnosis from an examination of the spinal fluid, the value of the examina- tion in poliomyelitis is necessarily less direct. Thus, in a fluid con- taining a high percentage of polymorphonuclear cells, the failure to find any organisms would certainly be suggestive of poliomyelitis. The difficulty of differential diagnosis is perhaps greater when one has a fluid with a lymphocytic cytology. Lucas has discussed at length the non-specificity of the cytoldgical findings in variou.s meningeal conditions, and finds a similar cell picture in encephalitis, poliomyelitis, meningism, tuberculous meningitis, and syphilis of the Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 107 central nervous system. Because, however, the examination of the •spinal fluid in poliomyelitis lacks specific diagnostic value, it would be wrong to conclude that it was not an important aid in diagnosis, or that lumbar puncture should not be performed in suspicious cases. Routine blood examinations and the usual urinary analyses have ^comparatively rarely a specific diagnostic value. Their greatest use- fulness consists in helping to rule out certain possibilities, and in focusing the attention on a narrower group. Within such a group the blood or urine examination, partly by itself, and partly when considered with clinical experience, may, by bringing either nega- tive or positive evidence, be the determining factor which points towards the correct diagnosis. The value of positive findings in spinal fluid examinations is undoubted. The value of negative •results in the examination approaches it in importance. Thus in the •case of poliomyelitis, the failure to demonstrate specific changes in the spinal fluid should rule out several serious meningeal conditions, the differential diagnosis of which from poliomyelitis in the pre- .paralytic stage may be most confusing. On the other hand, by the demonstration of non-specific changes, — for we have seen that by far the greater number of fluids in poliomyelitis are in one way or another abnormal, — a host of other conditions which may simulate incipient poliomyelitis are removed from further consideration. Among the small group of remaining possibilities, certain charac- teristic types of fluid, as, for instance, one with a high cell cotmt and a normal globulin reaction, may be of some value in deciding the diagnosis. More careful studies of the fluids in conditions other than poliomyelitis may throw further light on the differential value •of non-specific fluids. At any rate, when even the non-specific fluid of poliomyelitis is considered in association with the clinical features of the case, the diagnosis can probably be made in the great majority -of cases even in the preparalytic stage. The ease and safety with which lumbar puncture can be performed and the simplicity of the examination of spinal fluids should make the method much more widely used than it is at present. The value of any future method of treatment of poliomyelitis must depend on the possibility of early -diagnosis, for where the nerve cells have been destroyed, the results •■from any therapeutic measures will be comparatively small. Digitized by Microsoft® 108 A Clinical Study of Acute Poliomyelitis. Conclusions. — The spinal fluid from cases of acute poliomyelitis during the first few weeks after the onset of symptoms shows, in the great majority of instances, deviations from the normal. Fluids taken during the early days of the disease and especially before the onset of paralysis tend to show an increased cell count with a low or normal globulin content. At this early stage the poly- morphonuclear cells may amount to 90 per cent, of the total. Most fluids, however, show almost exclusively lymphocytes and large mononuclear cells. After the first two weeks the cell count usually drops to normal, or nearly normal, and there is frequently an increase in the globulin content. A slight increase in globulin may persist for seven weeks or longer. Analogous changes may be found in the spinal fluid of abortive cases. All fluids examined reduced Fehling's solution. The examination of the cerebrospinal fluid in acute poliomyelitis, while giving, as far as is yet known, no specific diagnostic criteria, is of the utmost value as an aid to diagnosis both in preparalytic and in abortive cases (see tables, pages 109, no, in, and 112). PROGNOSIS. Prognosis in poliomyelitis is a complicated problem. If death and recovery were the only results to be foretold, the matter would be no more difficult than in other infectious diseases, but there is the added uncertainty of the paralyses. In a given case seen in the preparalytic stage, for example, the question at once arises as to whether or not paralysis will appear at all. In another case seen on the first or second day, when there are marked general symptoms and when paralysis of a leg or an arm already exists, it is important to decide whether the process in the spinal cord will probably ad- vance or not. Finally the question of residual paralysis must be considered. The literature of poliomyelitis is fairly rich in mortality statis- tics, which form, perhaps, the best basis for prognosis as to life or death. Wickman's series of 868 cases showed a death rate of 16.7 per cent. The figures of numerous other observers are approxi- Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 109 TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS. The numerator of the fraction signifies the day of disease; the denominator is the day of the paralysis. The figure following is the number of cells per c.mm. of spinal fluid, o = normal globulin test ; v.s. + = faint precipitate (above normal) ; s. + = well marked cloud or slightly flocculent precipitate ; + = precipitate of large fiocculi; and ++ = heavy flocculent precipitate with the butyric acid test. •Si 1st week. 2d week. 3d week. 4th week. 5th week. 6th-ioth week; I f 31 V.S.+ -V- 7 V.S.+ « 6 V.S.+ 2 880 -+ ■ 627 1,221 + 3 1 7 + + if 5 + 4 f 10 S.+ Jf 46 S.+ n 5 S.+ II 4 V.S.+ 5 li 6 S.+ 6 tI 4 + + tI 4 + + + ?f 6 «. + II 7 s. + II 2 S.+ 7 § 13 + + n 19 S.+ if 7 ».+ If 6 V.S.+ 8 f 37 S.+ f 12 S.+ «9 9 is 30 + U 23 S.+ 10 ii 7 S.+ IJ 3 V.S.+ II i 120 12 fjio 13 f 30 S.+ 14 ¥- 21 S.+ IS 5 , "T 00 T 64 S.+ I6 i 39 S.+ if 13 + M 7 V.S.+ 17 il 29 + If 3 S.+ 18 U 16 + + + fj 20 + + + ft 16 + 19 fl 165 =.+ IJ 979 S.+ II 154 S.+ II 31 V.S.+ lis Digitized by Microsoft® 110 A Clinical Study of Acute Poliomyelitis. TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS (CONTINUED). II ist week. 2d week. 3d week. 4th week. 5th week. 6th-ioth week. 20 i 36 + it 154 S.+ If 12 S.+ If 20 + fiso 21 T 10 + if 6 + It 6 + U 2 S.+ 11 II S.+ 22 1 174 1 44 Y 119 S.+ 23 «ii + fSl2 + 24 * 6 t 62 s.+ l 59 S.+ Ji^SO 25 f 12 V.S.+ if 8 V.S.+ 11 10 V.S.+ M40 Ji4 26 1 16 S.+ ^ 10 v.s. + a 10 27 tI I + + T* 6 + U 2 S.+ If 2 V.S.+ 28 ¥ 6 + + ¥ II S.+ !f 40 IJ 10 114 29 i 10 s. + f 14 ++ if 3 + + if 2 + + Us + + ft S + It 2 + ff 3 V.S.+ 30 i 55 V.S.+ 1 295 S.+ 31 f 650 + 32 f 61 1 147 V.S.+ ¥7 + if I S.+ 33 i 160 + 34 i 58 S.+ 11 23 S.+ H 18 S.+ 35 1 297 + tI 38 + + if 27 ++ 118 + If 13 S.+ 36 -Y 26 S.+ if 12 + n 7 S.+ U 4 V.S.+ 37 f 69 S.+ 1* 9 =.+ II 8 V.S.+ ii3 38 tI 12 S.+ If 14 39 a 8 V.S.+ il3 + If 4 V.S.+ M 2 V.S.+ 40 f 13 S.+ H18 + if 7 + if 24 S.+ M 3 S.+ Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. Ill TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS (CONTINUED). Si ist week. 2d week. 3d week. 4th week. 5th week. 6th-ioth week. 41 1 — 22 42 -y- 4 27 T 9 + 29 — 3 V.S.+ 43 1 12 V.S.+ i?3 + i-l II S.+ H 155 + Jf 29 S.+ ff 49 + ii 10 44 5 39 S.+ «29 + H 53 V.S.+ ff 12 45 f 33 V.S.+ H I S.+ M30 46 f 37 f 44 V.S.+ 10 S7 ii II V.S.+ if 12 V.S.+ 47 lis + ¥ 12 + i|2S + M 2 V.S.+ 48 1 55 f IS + ^= 22 + if 2 + 11 3 + ft 2 S.+ If 4 fl3 S.+ v.s. + 49 f 8 V.S.+ if 4 V.S.+ if 40 SO f 42 S.+ if 30 + fi7 + ff 4 ff 6 S.+ S.+ SI f 83 S.+ V- 23 V.S.+ IJ II S.+ S2 1 58 S.+ 1 S- + ij6s.+ if 3 + fi 4 S.+ f?i v.s. + S3 ff 113 1 239 V.S.+ f 112 V.S.+ « 5 S.+ if 36 V.S.+ If 12 + ff 4 V.S. + 54 f 133 it 18 + fi 4 S.+ M3 55 f 20 V.S.+ f 55 v.s; + if 10 + 56 1 40 + n 35 V.S.+ i? 9 + li 8 S.+ a 6 V.S.+ 57 f 196 4I8S.+ it S S.+ 58 J 94 59 f 12 V.S.+ -V- 8 S.+ |§ 8 S.+ 60 f I8 1 90 V.S.+ if 3^.+ ff 3 61 i 203 H 18 + if 6 + 62 It 2 S.+ 63 i 473 S.+ 1 Digitized by Microsoft® 112 A Clinical Study of Acute Poliomyelitis. TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS (CONTINUED). u Eg ^0 1st week. 2d week. 3d week. 4th week. 5 th week. 6th-ioth week ^4 f 6i f 6o J 320 V.S.+ a 25 }f II V.S.+ '65 f 52 s. + 1! 14 S.+ U 7 V.S.+ 66 1 22 v.s. + 1 114 V.S.+ 67 11-40 6S f 26 -V- S + if S V.S. + 69 A 90 1 -V°- 14 ft 50 mately the same, the usual extremes being 10.8 per cent., reported by Zappert from the epidemic in Northern Austria of 1908, and 22.5 per cent, reported by Lindner and Mally*^ from the epidemic in East Austria in the same year. The mortality, furthermore, varies somewhat with the age of the patients. In younger children the outlook is better than in older ones and adults. Thus, Wickman found the death rate per cent, in patients below eleven years of age to be 1 1.9, and in cases between the ages of twelve and thirty-two, 27.6 per cent. Our series of seventy-one hospital cases showed a mortality of about 14 per cent. The figure, however, becomes much lower if the total number of cases applying for admission be used. In this total the death rate is 6.8 per cent. The hospital cases repre- sent, in general, the sickest patients that applied. While such statistics are of great value in giving a general con- ception of the fatality of the disease, they are of little help in the presence of a given case of poliomyelitis. This, of course, is true in some measure of all fatal diseases, but with acute poliomyelitis there is a peculiar element of chance not present in other general infections ; namely, the accident of the lesion destroying simultane- ously the phrenic and intercostal centers, an accident which is in- variably fatal. Unfortunately, there is no way of knowing where the lesion will occur, or if an existing lesion will advance. Flaccid legs, arms, or facial muscles point only to the cord segment most seriously injured when the case is first observed, and form no cri- " Lindner and Mally, Deutsch. Ztschr. f. Nervenh., 1910, xxxviii, 343. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 113 terioii of the extent or subsequent behavior of the lesion. Anterior horn cells that lie immediately outside the zone involved by the pathological process may continue to functionate properly, so that the proximity of the lesion to the phrenic and intercostal centers does not necessarily make the outlook worse. This and the fact that in most cases the initial lesion in the cord is the final one, and rarely advances, is perhaps the most encouraging knowledge that we command in attempting to make a prognosis as to life; for, as was pointed out in the section on paralysis, death in uncomplicated polio- myelitis invariably results from failure of the muscles of respira- tion. In other infectious diseases where death has been considered to depend upon toxemia, mortality statistics represent more nearly an average failure of human resistance, affected less, perhaps, by the element of chance. Consequently, at the bedside of a patient acutely ill with poliomyelitis, where the outward signs of the state of the disease are, from the nature of the malady, so unsatis- factory, the physician experiences an unpleasant sense of obscured vision. There are certain clinical features, however, which may help us in some measure to form an idea upon which to base prognosis as to life. Death, according to Wickman, occurs most often on the fourth day of the paralysis, the third to the seventh being the limit. In our cases, death occurred once on the second, four times on the third, once on the fourth, and once on the fifth day of the paralysis. Figuring, however, not in days of paralysis, but rather from the onset of the disease, the fifth day has been the most fatal, with limits from the fourth to the eighth days of the disease. We therefore made it a rule not to declare children out of danger until after the eighth day from the first appearance of muscular weakness. Usually, the fatal cases are very ill in the first two or three days, and in our series all had paralysis of one or both deltoids ; that is, an involvement of the cervical cord. The extreme prostration and the upper extremity paralysis, unless the case was of the rapidly ascending type (Landry), have been the only tangible prognostic features. An impression, however, derived largely from the pa- tient's psychic state, has helped materially. In practically all the fatal cases the peculiarly alert cerebration, described under the sec- Digitized by Microsoft® 114 A Clinical Study of Acute Poliomyelitis. tion on the fatal cases, has been present. None of the profoundly stuporous or highly irritable cases have died. Consequently, we have been glad to see patients in the early days either irritable or drowsy. One case, in particular, recovered, whose rapidly as- cending paralysis, first involving both legs, then one arm, then the back and neck, had led us to give a bad prognosis. This patient was very drowsy, and was irritable if disturbed. Paralysis of either diaphragm or thoracic musculature abne is not necessarily of bad prognostic significance. Children with such involvement, however, are rather prone to develop bronchopneu- monia, which is then almost always fatal. Nevertheless, we saw one instance in a boy of twenty-one months, who reached the hos- pital with a paralyzed diaphragm and a resolving consolidation of lobar pneumonia. He made a good recovery. Another equally difficult question in the prognosis in poliomye- litis is that which arises during the preparalytic stage ; namely, will paralysis occur, or not? As in the rapidly advancing cases, where it is impossible to know whether or not the respiratory muscles, are about to fail, so here the same sense of obscured vision baffles the physician. We have found absolutely no certain way of antici- pating paralysis. Occasionally the patient may complain of pain in a member which is subsequently lamed. This is unsatisfactory, however, because pain in general is such a common feature of the disease. Furthermore, the disappearance or absence of a knee jerk is no infallible signal of approaching weakness. One abortive case which we observed practically from the day of onset through- out the course, was the source of hourly apprehension for eight days. At one time, on the third day of the disease, the knee jerks, which had been exaggerated, became much less easy to obtain. Three days later the left knee jerk reacted on reenforcement only, but no paralysis developed. In a similar way it is impossible to determine whether or not an advancing paralysis is about to stop. As a rule, although figures on this point are inaccurate and unconvincing, our experience has been that the initial paralysis is final. Nevertheless, there are enough examples of late involvements to make the antici- pation of further paralyses quite justified at any time until the seventh or eighth day. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 115 A discussion of the prognosis in poliomyelitis necessarily involves a consideration of the ultimate disability caused by the disease. It w^as formerly supposed that the paralysis vi^as always permanent. Wickman's extensive studies, hovirever, and the report of the Massa- chusetts State Board of Inquiry showr that this fortunately is far from the truth. For example, of the 530 cases, one to one and a half years after the acute attack, which were analyzed by Wickman, 56 per cent, were paralyzed, and 44 per cent, were cured. The records from Massachusetts indicate a considerably lower percentage of complete recoveries, — 16.7 per cent. Complete return of power is more apt to occur in children than in adults. It is still too early to be able to report figures of value from our hospital cases. We have, however, been much struck by the surprising return of power which may occur after a few weeks in limbs that seemed hopelessly para- lyzed, and we have been even more impressed with the marked im- provements occurring after several months of a stationary condi- tion of the paralyses. TREATMENT. At the present time there is no specific form of therapy by which the paralyses in acute poliomyelitis may be prevented, or by means of which resolution of the inflammatory process and, consequently, return of function may be hastened. The problem of treatment, therefore, consists in preventing the spread of the disease to other persons, in applying general symptornatic procedures, and in attempt- ing the restoration of muscular efficiency and the prevention of deformities. Inasmuch as the direct contagiousness of poliomyelitis and its dissemination by healthy intermediaries are now definitely estab- lished facts, the maintenance of strict quarantine is essential for the public health. In this disease, which in its sporadic form has been with us so long, and towards which there is apparently a high indi- vidual immunity, it is peculiarly difficult to convince many persons, both lay and medical, that a quarantine is not somewhat superfluous. Recent investigations, however, which show that in some epidemics the number of families or houses with more than one case may reach 40 per cent.; that "persons have been attacked by poliomyelitis Digitized by Microsoft® 116 A Climcal Study of Acute Poliomyelitis. several days after a short and single contact with a patient " f° that markets, fairs, schools, and public gatherings may be the means of spreading the disease; that transmission by fomites probably occurs; that the virus may exist in the saliva and nasal mucous membrane in monkeys and in the tonsils in man ; and that it may also be found in the dust from the rooms of patients, have convinced public health authorities that poliomyelitis should be treated like any other defi- nitely contagious disease. In Sweden, Norway, Germany, many provinces of Austria, and in a number of states in this country, poHomyelitis is one of the diseases in which notification, quarantine, and disinfection are required by law. We have already mentioned the outbreak in Nebraska in 1909, which was apparently checked by imposing an absolute quarantine for three months on all members of a patient's family with the exception of the bread winner. The Paris Academy of Medicine recommends the passage of a law which would "allow the interdiction of school attendance for three months, and would apply equally to patients and convalescents." It is prob- able, however, that the general enforcement of such prolonged quar- antine would work hardships which would scarcely be compensated for by the results obtained. The question as to how long the disease ought to be considered contagious is a most difficult one. That the disease is contagious during the prodromal stage and perhaps also during the incubation period is, unfoitunately, extremely probable. Some authorities believe that isolation should be continued through the acute stage of the disease, until the subsidence of pain, hyper- esthesia, and all acute symptoms. In our own work we have drawn a rather arbitrary line based on the fact that in the experimental disease in monkeys, the virus rarely persists after three or four weeks. That it may persist longer in monkeys, and probably also in human beings, is of course certain, but we have felt that this gave the best practical rule for hospital purposes. We have endeavored, therefore, to isolate the children in the hospital until about four weeks after the onset of the disease. We have then allowed them to go home, but have urged that, when possible, they be kept apart from other small children for several weeks more. °° Notification of Poliomyelitis— Translation of a Report Presented to the Paris Academy of Medicine on "Obligatory Notification of Poliomyelitis (Infantile Paralysis)," Public Health Reports, 1911, xxvi, 1602. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 117 During their stay in the hospital, the patients with poliomyelitis were kept in an isolation ward apart from all other patients. Sus- pected cases with uncertain diagnosis, or cases proving not to be poliomyelitis were placed in separate rooms and completely isolated. Nurses on duty in the ward never came in contact with patients in other parts of the hospital, and the same was usually true of doctors. All doctors and nurses wore caps and long gowns when working with the patients. When leaving the ward, the hands were thoroughly scrubbed with soap and a nail brush, and soaked in cor- rosive sublimate. The occasional use of a hydrogen peroxide gargle or nasal spray (i per cent.) was recommended. Visitors were admitted on two days in the week, but only one visitor to a patient. All visitors were compelled to wear gowns while in the ward, to wash carefully and disinfect the hands in corrosive sublimate, and use a hydrogen peroxide mouth wash on leaving the ward. The clothes worn by patients on admission were disinfected by stean^ under pressure. Bedclothes and nightgowns were passed through a sterilizing washer. Thermometers were kept in corrosive subli-^ mate. Bedpans and urinals were boiled after using. All urine and feces were sterilized by heat in a steam sterilizing hopper. After- being used, the rooms were disinfected with formaldehyde gas, and. the walls and floors were thoroughly scrubbed with soap and water. The general treatment of the acute stage of the disease as regards; diet, bathing, catharsis, etc., should be carried on exactly as in other infections. As soon as the children showed a desire for a liberal diet, it has been given to them. After they have passed the early acute stage, they are apt to have unusually large appetites. Dur- ing the acute stage absolute rest in bed is, of course, a necessity in most cases, but even when the children feel well, it is probably wise to keep them quiet for a week or two after the onset of paralysis. At this early period, the most prominent indication for treat- ment is usually pain. In some instances, as we have seen, pain may be spontaneous, but much more frequently it is associated with movement of the limbs, and this necessitates the utmost gentle^ ness and care in moving or turning the child and changing the bed linen. When lifting or moving a patient with marked hyperesthesia, the nurse should try to avoid flexing the neck or the hips, or bend' Digitized by Microsoft® 118 A Clinical Study of Acute Poliomyelitis. ing the spine forward, as these are the most painful motions. Not infrequently, this pain is so great that the children develop a dread of being touched, and they cry out long before they are actually hurt. The nurse who realizes that their pain may be intensely severe, whose touch is gentle, and whose voice is reassuring, may do much towards preventing this unhappy state of mind. In patients with spontaneous pain or with tender muscles, the weight of the bedclothes may be sufficient to cause discomfort, and a cradle to raise them ofif the limbs is often a relief. In other cases a light, well padded splint seems to steady the limb and to take the strain from unaffected muscles. One of our children used to beg to have the splint replaced when it was taken off. In general, the most effective simple agent for overcoming pain seems to be heat. This is especially the case in paralyzed limbs which are often very cold and clammy. Wrapping the limb in cotton wool, blankets, hot packs, and hot water bags gives great comfort. We have frequently had occasion to notice the effect of cold weather and dampness on these patients, when a sudden change from warm summer weather to a cold rainy day would be accompanied by definite exacerbations of pain. The ward was, therefore, kept at a warm, equable tem- perature. A certain proportion of cases suffer so intensely that simple measures are not sufficient to control the pain, and drugs have to be resorted to. Bromides we have found helpful in little children. In older patients phenacetine, aspirine, codeine, and occa- sionally hypodermic injections of morphine are necessary. We have never felt convinced that lumbar puncture was of any therapeutic value. In one fatal case life was apparently prolonged for a short time by means of artificial respiration. Landolt^^ reports a case in which artificial respiration was carried on almost constantly for seventy-two hours. During this period there was slight return of power in the toes and fingers, but the patient finally died. Theo- retically, it would seem that one might possibly tide a person over by artificial respiration until an absorption of exudate allowed the nerve cells controlling the respiratory muscles to resume their function. During the early part of the disease the most important indica- "Landolt, Cor.-Bl. f. schweis. Aerste, 1911, xli, 1144. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 119 tion is for complete rest and quiet. When the acute symptoms pass, however, more active treatment directed tovv^ards the prevention of deformities and the restoration of muscular function should be instituted. The exact period at which it is best to begin treatment varies, but in general the pain seems to be a good guide. As soon after the first fortnight as the child can bear any movement or handling without pain, massage should be begun. It is important, although sometimes difficult, to distinguish between true pain and the fear of pain which may persist until the child's self-confidence is restored. ' Contractures begin to develop early in poliomyelitis, and it is essential that they should be guarded against from the onset. The most common early deformity to be dealt with is the toe drop, occur- ring from the contraction of the flexors of the toes and extensors of the foot in the absence of normal opposing muscles. Such a de- formity is hastened by the pressure of the bedclothes, so that a cradle is useful where it is feared. Sand bags may be used to sup- port a limb ; or light apparatus, such as a posterior wire splint with a foot-piece at right angles, may be sufficient to overcome the pull of the muscles. Such apparatus must be well padded and the straps applied, loosely so that there is no obstruction to the circulation. The danger of apparatus is that it will keep the limb too quiet and pre- vent any attempt to use weakened muscles at precisely the period in which both active and passive motions are most to be encouraged. To obviate this, it has been our custom to have the apparatus ap- plied at night only, and to leave the limbs free to move during the day time. Massage is a most helpful aid to treatment. We have begun with light massage as soon as the pain would allow, and given it twice daily. Its chief usefulness probably consists in assisting the circu- lation by replacing the effect of lost muscular activity. Heat, and especially baking, also exert a good influence on the circulation. With massage, passive motion is used, the rhythmic performance of certain movements stimulating the patient to try to attempt them himself. Of all methods, however, by far the most valuable one is active movement, or muscle training. In attempting voluntarily to use a weakened or paralyzed muscle, the patient can accomplish Digitized by Microsoft® 120 A Clinical Study of Acute Poliomyelitis. more for himself than can ever be done for him by anyone else. Muscle training is comparatively easy to carry out with adults or children old enough to do what they are told, but with little children, who by instinct avoid the use of an;^ injured muscle, and try only to accomplish the same result by means of another healthy group of muscles, the problem is more difficult. In one way or another, the child must be made to attempt to use the weak muscles. It is here that the skill of the nurse shows itself. By merely teUing the child to move an arm or leg, she accompHshes nothing, and as likely as not merely makes him suspicious and obstinate ; but by playing with him, coaxing him, inventing ingenious games, which involve the use of muscles without his realizing it, and by showing infinite patience and tact, the end is obtained. Frequently, the children use their limbs better when they are in a warm bath than when in bed. The excitement of the tub bath and the fun of playing with floating toys makes them forget their disabilities, and they try new move- ments much more readily than in bed. Probably also, the heat and the buoyancy of the water make many muscular movements less difficult. Some children are ambitious and from the outset are continually anxious to progress, but with many each new step in- volves a struggle. One literally has to force them to try to sit up, to try to stand, and then to try to walk. Dr. Charles West®^ dis- cusses some methods of stimulating children to use their paralyzed limbs and then adds, " I need not say that much care and much patience are needed in carrying out any of these suggestions, and not a little of that intuitive love for children which teaches those who are its possessors how to extract fun and merriment from what might in other hands be a most irksome task." In the therapeutic use of electricity, we have had little personal experience. To be of any value, electrical treatment must be given with considerable skill and over a long period of time. The amount of other work entailed by the large number of patients we have had in the hospital left us no opportunity to take up this method of treatment. The general methods which may be of service, however, are summed up in the following sentences from the report of the "' West, Lectures on the Diseases of Infancy and Childhood, 3d edition, Lon- don, 1854. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 121 Massachusetts State Board of Health^* for June, 1909: "In the early stages, galvanism should be used on the nerve trunks and faradism on the muscles, so long as their irritability for contraction is maintained. When the irritability of contraction to the faradic is lost, galvanism should then be used, as having more influence on nutrition. With the returning muscle irritability, faradism should be used, and best by the use of the electrodes over the muscle points so as to obtain actual contraction of muscles rather than by the application of the electrical current to broad surfaces. This serves as a distinct exercise to the muscle during its early stage of weak contraction." The results of treatment depend to a great extent on the faithful- ness with which it is persisted in. Coincident with the absorption of the exudate, improvement is often quite rapid during the first weeks and months; then follows a long period which may be intensely discouraging in its apparent results, a period in which im- provement is probably due to muscle training and to the assumption of new functions by the surviving nerve cells. During this period the patient learns many tricks by which surviving muscles may be made to assume in part the role formerly played by those which have become paralyzed. A slow recovery often continues for a very long time, and to be sure that the muscles have regained all the power that they are capable of, conscientious treatment ought to be continued for at least a year and a half or two years. We have been greatly impressed with the marked improvement which may come after the end of the first year. The problem as to when the case ceases to be a medical one and should be turned over to the orthopedic surgeon is difficult and much discussed. The danger of a too early resort to surgery and mechanical methods of support is that the patient will come to rely too much on these methods and cease developing his muscles to their utmost. Internists and neu- rologists thus tend to postpone calling in the orthopedic surgeon until they feel satisfied that they have done all in their power. The danger of this delay, on the other hand, is that deformities may set in which make the corrective problem much more difficult, so that the orthopedic surgeon receives the case at a distinct disadvantage. "^Report of the Massachusetts State Board of Health, loc. cit. Digitized by Microsoft® 122 A Clinical Study of Acute Poliomyelitis. The best treatment would probably mean a cooperation in which the surgeon would foresee and correct deformities and the internist would protect the interest of the injured muscles. When one member of a family is taken sick with poliomyelitis, the physician must take what measures he can to prevent the spread of the disease to other members of the family and to the com- munity at large. Strict isolation of the individual case and isolation of those who have been in close contact with it during the fortnight preceding onset, are the most efficient measures. This is particu- larly important with regard to the prevention of contact with chil- dren. Attendance at school, church, or other places of public meet- ing should be forbidden for at least three weeks. As direct treat- ment for those exposed, urotropin, which by animal experimenta- tion has been shown to have some slight action in destroying the virus, may be given for about a week. Longer administration is not advisable. Nasal and throat sprays or a gargle of i per cent, peroxide of hydrogen or of a 0.5 per cent, menthol solution should be used, but only for a few days, for their prolonged use is irri- tating and may make the throat and nasal passages more susceptible. CASE HISTORIES. Sherman R., age, 17 months. Ridgewood, L. I. Admitted, September 20, 1911. Discharged, November 8, 191 1. Result, improved. Diagnosis.— Acuts poliomyelitis. Family History. — Negative. Past History.— The child has never been sick before. Present Illness.— Thursday morning, September 13, seven days ago, the patient was perfectly well. In the evening he vomited some chocolate which he had eaten. There was high fever that night and all the next day. The child was drowsy and wanted to be let alone. He had no convulsions, but is said to have been, "twitchy." On Saturday his fever fell. The temperature was normal on Sunday, and the doctor thought the child would be well. He was drowsy and dull, however, all day. On Monday he seemed to have difficulty in swallowing and later in the day the doctor noticed that he could not use his legs. He has been constipated. The child is teething. Physical Examination.— The patient is a well nourished, drowsy, small boy, who is fairly easily aroused and resents being handled. His head is usually held on one side and slightly retracted. Eyes.-Pupih are equal and react normally. Ocular movements are normal. £a«.-Normal. Nose.—T^ years. Port Richmond, S. I. Admitted, July 15, 1911. Dis- charged, August 22, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat: the family lives in a tenement with four other families. The house is clean. The child has one cousin who had infantile paralysis eight years ago. This girl has seen the child once since it hecame sick, but previously had not seen the child for a long time and very rarely came in contact with it. There is no history of any other possible contact. Past History. — Three years ago he had bloody dysentery followed by dropsy and swelling of the feet which lasted two weeks. He had whooping cough as an infant and measles at two years. Present Illness. — Three weeks ago the child was taken with a headache and fever. The next day he fell on the floor and hurt his heel. Since then he has not been able to stand on his heel, but only on his toes. Two days later he " took a sleepy spell " and would not eat. That night both legs gave way when he was trying to stand. The next morning the doctor saw him and made a diagnosis of sprained ankle. The mother noticed that both legs were powerless. Since then he has been in bed. Two days after the onset of paralysis, he began to complain of pain in the legs. He has not been especially restless, he sweats a good deal after the onset. He has not vomited and has had no chill. On July i he was unable to pass urine and on July 2 was taken to the Smith Infirmary. While in the hospital he had to be catheterized for two -or three days. Since July 2 he has heen at the Smith Infirmary. The mother never noticed that the child was cross- eyed. The patient was transferred here from the Smith Infirmary. Physical Examination. — The patient is a well developed and nourished boy. The skin is clear and warm, lips and conjunctivae are of good color. Eyes. — The eyes move normally. There is an internal squint in the right eye. Pupils react normally. Ears. — Normal. There is no tenderness over the mastoids. Nose. — No discharge. Mouth. — ^The tongue is clean and protrudes straight. Teeth are in good condition. Tonsils are slightly enlarged but not ragged. Neck. — The neck resists flexion but there is no retraction. Superficial lymph nodes. — There are very small lymphatic glands felt in the neck, axillae, and groins. Chest. — Symmetrical and well developed. Heart. — Normal. Lungs. — Negative. Abdo- men. — Full, soft, symmetrical, and tympanitic, no masses or tenderness, abdominal reflexes are active. Liver. — Flatness extends from the sixth rib to the costal margin. Spleen. — Not felt. Muscular system. — Arms : muscular movements are normal. Legs: knee jerks, Achilles, Babinski, and Oppenheim reflexes not ob- tained on either side. Kernig's sign : there is no true limitation of motion, but flexion of the hip with extended leg is very painful. There is no pain on pres- sure except perhaps over the left calf. On extension of both legs he complains Digitized by Microsoft® 126 A Clinical Study of Acuie Poliomyelitis. of pain in the popliteal spaces. Paralysis.— Thtrt is apparently complete flaccid paralysis of both legs. Child is unable to move any of the muscles. He cannot wriggle his toes and cannot flex the thighs on the hips. There is double toe drop. The child is unable to sit up on account of the pain in his legs. There is apparently no weakness in the muscles of the back. Temperature.— gg.2° F. July i6. The temperature is normal, chest clear, and general condition very good. There is a slight internal squint of the right eye. July 17. Blood count: leukocytes, 12,000; differential count of 200 cells: polymorphonuclears, 58.5 per cent; small mononuclears, 27.9 per cent.; large mononuclears, 9 per cent; eosinophiles, 3.5 per cent.; transitionals, 2 per cent, red cells normal; platelets normal. Spinal fluid: 25 c.c. obtained; pressure slight; slightly bloody; specimen used for cell count was very opalescent ; an almost turbid fluid with only a very slight pink tinge. Cell count, 529 per c.mm. ; differential count of 200 cells; poly- morphonuclears, 45 per cent. ; mononuclears, 55 per cent. ; globulin, + + ; albumen, + ; sugar, +. July 20. Paralysis is unchanged, and is complete in the legs. There is marked pain in the back of the thigh on moving the right leg, and there is also pain on dorsal extension of both feet with legs extended. Spinal fluid: 25 c.c. of opalescent fluid of slightly yellowish tinge; slight increase of pressure; no clot formed after 24 hours; cell count, 524; smear; differential count of 200 cells : polymorphonuclears, 60.5 per cent. ; mononuclears, 26 per cent; endothelial, 13.5 per cent; globulin, +; albumen, + (faint cloud) ; sugar, +. July 21. The temperature this evening is 101.8° F. The child has a headache and feels miserably. As soon as he is moved he complains of severe pain. This is localized, at times in the legs, at times in the back, and frequently in the abdomen in the region of the navel. It is difficult to make out the cause of the pain, but it is apparently associated with movements of the legs. July 22. The temperature was normal this morning but has risen again to 103.4° F. The child is very uncomfortable when moved. The neck is quite stiff. The ears, eyes, and throat are negative. Heart and lungs (front) are negative. The abdomen is negative. Knee jerks are absent. It is difficult to localize the pain. He says it is worse at the inner side of the left knee, just below the inner tuberosity of the tibia, but when he is moved he has great pain in the lower part of the back, and back of the thighs. There is no especial tenderness. Leukocytes, 15,100 (82 per cent polymorphonuclears — wet count). July 23. The temperature has come down. The child cried a great deal during the night, partly from pain and partly not. The lungs are clear; the abdomen is soft with no tenderness. July 24. Leukocytes, 14,800 (85 per cent, polymorphonuclears— wet count). The neck is very stiff and markedly retracted and is painful on flexion. Kernig's sign: there is much pain in the legs on an attempt to elicit the re- action; no spasm of muscles. July 27. The fever is less, and the pain less. Extension of the legs is stilt painful, and the legs are somewhat tender ; there is no retraction. Flexion is less painful, but complete flexion is distinctly painful and is resisted. Chest and abdomen are clear. There is marked atrophy of the legs. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 127 July 28. Blood count: leukocytes, 6,300; differential count of 200 cells: polymorphonuclears, 62.5 per cent. ; small mononuclears, ig per cent. ; large mono- nuclears, 12 per cent. ; mast cells, i per cent. ; transitionals, 3.5 per cent. ; eosino- philes, 2 per cent. July 30. The child looks much better. The head flexes more easily, but flexion is still painful. August 9. Spinal fluid: 25 c.c. of perfectly clear watery fluid; pressure slightly increased ; cell count 30 per c.mm. ; smear : small mononuclears, 82 per cent. ; large mononuclears, 18 per cent. ; globulin, + (slight flocculent precipitate) ; sodium chloride, 0.74 per cent. August 16. Spinal fluid: 20 c.c. of perfectly clear watery fluid; no blood; pressure slightly increased; cell count, 23 per c.mm.; mononuclears, + (occa- sional polymorphonuclears) ; globulin, slightly + ; sugar, -f-. August 18. Blood count: leukocytes, 10,700; differential count of 200 cells: polymorphonuclears, 52.5 per cent. ; small mononuclears, 35.5 per cent. ; large mononuclears, 9 per cent.; eosinophiles, 0.5 per cent.; transitionals, 2.5 per cent. August 20. The child is much better and sits up very well. The chest is clear. There is no pain on flexion of the neck and no pain in the legs. The abdominal and back muscles are normal. He can flex the toes of the left foot, otherwise there is complete paralysis of both legs. August 22. The general condition is much improved. The child has no pain and sits up well, but cannot stand. There has been practically no return of movement in the legs. CASE 4. Hannah T., age, 4 years. New York City. Admitted, October 3, 191 1. Dis- charged, October 29, igii. Result, improved. Diagnosis. — Acute poliomyelitis. Past History. — The patient has always been a strong healthy child. Present Illness. — On Sunday, October i, two days ago, the child was perfectly well in the morning. In the afternoon she was " kind of heavy and wanted to go to bed." That evening she vomited, slept poorly, and was restless. On Monday morning, when she got up and tried to walk, she fell. She tried again to walk, but again fell. Later in the day she said she felt well and wanted to get up, but on trying to walk, fell a third time. This morning she vomited. She has had no convulsions, has been constipated, and sweat heavily on Sunday night. She is said to have had fever. Physical Examination. — The patient is a well nourished little girl who lies quietly on her back and tends to be drowsy. When she is aroused, she becomes greatly excited, frightened, and trembles. She objects to being handled. The breath has a heavy, sweetish odor. Eyes. — Pupils are equal, react normally. Ocular motions are normal. There is marked photophobia. Ears. — Normal. Nose. — There are a few, small, dried scabs on the inner margin of the external nares, no secretion. Mouth. — The lips are dry, the tongue heavily coated. Buccal mucous membrane is clear. Pharynx is slightly reddened. Tonsils are not very large. Superficial lymph nodes. — The posterior cervical, axillary, and inguinal nodes are palpable. Neck. — Anterior muscles seem a little weak. Pos- terior muscles resist attempt at flexion. There is no retraction. Thorax. — ^Well formed, moves properly in respiration. Lungs. — Clear. Heart. — ^A little rapid, Digitized by Microsoft® 128 A Clinical Study of Acute Poliomyelitis. otherwise normal. Abdomen. — Soft, not distended, no tenderness or masses. Liver. — Edge felt about two fingers' breadth below costal margin. Spleen. — Edge just felt below costal margin in anterior axillary line. Extremities.— Upper: normal. Lower: there are no paralyses, but there is inability to stand. Both hip and knee joints buckle when weight is put on the lower extremities. There is apparently no definite weakness of the glutei, so that the trouble prob- ably lies in weakness of the quadriceps extensors. Knee jerks and Achilles re- flexes are absent on both sides. Babinski reflex is absent on the left and on the right. Kernig manipulation is not resisted and causes very little pain. Tem- perature. — 101.2° F. October 3. Blood count: leukocytes, 17,600; differential count: poly- morphonuclears, 44.S per cent. ; lymphocytes, 37.5 per cent. ; large mononuclears, 3 per cent; transitionals, 14.5 per cent.; basophiles, o; eosinophiles, o; stimula- tion form, 0.5 per cent. Spinal fluid: 20 c.c. of clear limpid fluid; pressure not increased; cells, 196; mononuclears, ++; globulin, shghtly hazy; sugar, -|-. October 5. The child is very irritable and complains of pain on being moved. The left ankle and foot are especially painful. The right quadriceps is appar- ently paralyzed, also the right peroneal group. The child lies on her side with marked retraction of the neck. There is great pain on flexion of the legs. Examination is difficult because of great irritability and the rigidity with which the body is held. In the afternoon, the patient complains bitterly of pain in her feet. Com- plete paralysis is evident in both quadriceps. October 6. The patient is lying quietly on her left side with head retracted. She is apparently not suffering from pain at this moment. Flexion of the neck is painful. The legs are not especially tender on pressure, but are very painful when she makes an attempt to move. October 8. The pain seems to be somewhat less, but at times is so severe that she cries out from it. Both legs are very tender to pressure, apparently more so over the nerves. Movements of the legs are very painful, in fact, her legs have to be left in one position and motion cannot be tested. October 9. The pain is perhaps a little less, but she cannot bear to have her legs moved. October 10. There is pain when the muscles are squeezed. October 12. The child still has much pain. She is very much afraid of being touched, as she has had so much pain, and it is hard to tell just how much is pain, and how much is nervousness. She has suffered so that she does not tell the nurse when she wishes to void, or when her bowels move, apparently dreading being put on the bed pan. Spinal fluid: 15 c.c. of clear watery fluid, no increased pressure; cell count, '8 per c.mm.; globulin, slightly 4-; sugar, +. October 14. The child is much better. For the first time she responds when ■spoken to and gives her hand. The arms move normally. Flexion of the neck is painful. Movement of the legs is still very painful, so that they cannot be tested for paralyses and reflexes. October 18. The patient says she has not so much pain in the legs this morn- ing, though she complained of it last night. If they are manipulated, however, Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 129 she cries out. The left knee jerk is present; the right, absent. The patient apparently has little power over the lower extremities. Flexion of the neck causes pain and the patient resists actively all attempts to make her sit up. She throws the head far back when this attempt is made. October 20. Spinal fluid: cells, 5 per c.mm. ; mononuclears, +; sugar, + ; globulin, slightly +. October 29. There is surprisingly little improvement in the tenderness of the spine and legs. The slightest movement towards flexion of the thigh causes intense pain, and the patient will not and probably also cannot move the lower extremities. The general condition is better. The patient is less moody. October 29. The patient's mother insisted on taking her home. When the mother dressed her, the child did not complain of pain as she does when doctors or nurses touch her. CASE S. John O., age, 21 months. New York City. Admitted, July 25, 1911. Dis- charged, September 23, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat : the family lives in a tenement house. There are eleven other families in the house. They have five rooms on the ground floor. There is good light and fair ventilation. The only parasites that have been noted are bedbugs. The father states that these are worse in the children's room. The father is in good financial circumstances, is a fireman and has been working on a fireboat for the past eleven months. In his duties be has not been called into any house where there was infantile paralysis; in fact, he has been on the boat constantly. Past History. — The child has grown well, and has always been in excellent health. Present Illness. — Friday evening, July 21, four days ago, the child was slightly feverish and his face flushed. He took his supper as usual. The next morning he was still slightly feverish but took his breakfast. He complained of headache and pain in the stomach but could walk as well as usual. In the afternoon the mother took the child out in a carriage, and she noted that when he got out he did not want to walk but preferred to be carried. If supported, how- ever, he could walk almost as well as usual. Two days ago, the fever was more marked, and the parents noted that there was some weakness of the legs. They noticed that when the physician examined him at that time, in stimulating the plantar surfaces of the feet he could wriggle the toes, although he could not flex the legs. He could, however, sit up in bed. Yesterday he could not sit up in bed, and absolutely no movements of the lower extremities could be obtained. Two days ago the fever was 103° F. Yesterday it was somewhat lower. The child has had but little appetite and has taken only milk and a little broth. Castor oil has been given each day, but an enema has been necessary to move the bowels. When the patient was quiet in bed, he did not seem to suffer much pain, but when moved, seemed to have a great deal of pain in the back and legs. This morning he seemed weaker than at any previous time. His cry to-day is noted to be rather weak. There has been no vomiting, and there have been no con- vulsions. Physical Examination. — The child lies on his back with his head rotated Digitized by Microsoft® 130 A Clinical Study of Acute Poliomyelitis. to the right. The skin is warm and moist. The child looks dull. Head. — Well formed, fontanelles closed. Ejiw.— No ptosis, no strabismus. Ocular move- ments are good. Pupils are equal and react to light. Sclerae and conjunctivae are clear. Ears. — No discharge, no tenderness. Nose. — No discharge. Mouth. — The lips and mucous membranes are of good color. Teeth are well formed, tongue has a moderate white coat. The mouth is drawn slightly to the right on crying. No exudate on the pharynx or tonsils. The right tonsil is enlarged, the left just visible. Neck.— Tht head is rotated to the right, resists rotation to the left or flexion towards the chest. Flexion causes pain. When the child is sitting up, the head drops back, although it can be brought forward. There is evident weakness of the muscles of the neck. Superficial lymph nodes. — The cervical and axillary nodes are palpable and slightly enlarged. CAcJf.— Well formed, costal angle wide. The chest moves with respiration slightly. There is more expansion on the left than on the right. Breathing is partly costal and partly diaphragmatic. Lungs. — Negative on auscultation and percussion. Heart. — No increase in size on percussion. Apex impulse is neither visible nor palpable. Heart sounds are clear and forceful. No murmurs are heard. Abdomen. — ^Well rounded, moves easily with respiration, not distended, no tenderness, no masses or rigidity. Liver. — Dullness extends from the fifth interspace to the costal margin in the right mammary line. Edge is not felt. Spleen. — Not felt. External genitalia. — Normal. Extremities. — Upper: movements of the arms seem normal. Brachial reflex is active on the left, not obtained on the right. There is no wrist drop. Lower: there is complete flaccid paralysis of all the muscles of both legs. No reflexes can be obtained, no Kemig's sign. There is no apparent muscular tenderness. Temperature. — 100.4° F- July 26. Spinal fluid : clear, colorless, not opalescent ; pressure not increased ; cell count, 10 per c.mm. ; globulin, slightly + ; differential count : mononuclears, 88 per cent.; polymorphonuclears, 8 per cent.; endothelial cells, 4 per cent. July 27. Blood count: leukocytes, 15,700; differential count of 200 cells: polymorphonuclears, 53.5 per cent. ; mast cells, i per cent. ; small mononuclears, 28.S per cent. ; large mononuclears, 12.5 per cent. ; transitionals, 4.5 per cent. ; eosinophiles, o. July 29. Spinal fluid: 20 c.c, for the most part perfectly clear and watery; pressure apparently slightly increased; cell count, 14; smear contains a few red cells ; mononuclears, 70 per cent. ; endothelials, 20 per cent. ; polymorphonuclears, 10 per cent. ; globulin, + -f ; sugar, + . August I. Chest and abdomen are clear. The child's general condition im- proves very slowly. He does not get much brighter and cries or groans most of the time when not left alone. Physical examination does not show sufficient reason for his poor condition. August 3. yon Pirquet reaction positive in 24 hours. When sitting up, the child can hold his head up for a short time, then it drops backward. The body is not supported from the hips. It falls forward so that the body and the thighs lie almost parallel, the body completely doubled up. Spinal fluid: IS c.c. of perfectly clear watery fluid ; no increase of pressure; cell count, 3 per c.mm.; globulin, + -f (heavy flocculent precipitate). August 4. Blood count: leukocytes, 22,000; differential count of 200 cells: polymorphonuclears, 46 per cent.; lymphocytes, 38.5 per cent.; large mono- Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 131 nuclears, 0.5 per cent.; transitionals, 11 per cent.; basophiles, 0.5 per cent.; eosinophiles, 3.5 per cent.; stimulation form, o. August 5. The patient continues to lie in a listless fashion without taking much notice of his surroundings. There is no change in paralysis. The neck is weak in supporting the head when the patient sits up. August 9. Spinal fluid: 25 c.c. of clear colorless watery fluid; no increase of pressure; cell count, 2 per c.mm. ; smear, almost all small mononuclears; an occasional polymorphonuclear; globulin, +' + (fairly heavy flocculent precipi- tate) ; sodium chloride, 0.72 per cent. August 14. The child is still hypersensitive and timid. He begins to cry and sob as soon as any one approaches him and starts to examine him. The ne ■ is resistant and flexion painful. When he sits up, the head drops over backwards. Sitting up is apparently very painful. He flexes and extends his hands and fore- arms, but when trying to raise the upper arms, he hunches his shoulders. There is paralysis of the shoulder muscles on both sides. Mentally, the child is hard to rouse and takes no interest in anything around him except in his food, which he takes well. He sweats very freely. There is a peculiar disagreeable odor to the skin. August 25. The child seems much brighter and more interested in things. He plays a little. The nurse says he seems less tender when she handles him. He began to talk more yesterday. The paralysis is not changed. September 3. The child seems rather bright. The head is held steadily on sitting up, though some weakness is still present in the neck muscles. All reflexes of the legs are still absent, paralysis of both legs being still complete. Move- ments of the right arm are good. The left forearm is weak. There is wrist- drop and the hand is held in a claw-like attitude. CASE 6. Jennie A., age, 20 years. New York City. Admitted, July 18, 191 1. Dis- charged, October 5, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Past History. — The patient has always been healthy. Present Illness. — On July 14, four days ago, patient had pain in both legs, principally in the thighs. She rubbed her legs with alcohol, and the pain dis- appeared. The next morning she got tap, cooked the breakfast, but afterwards felt feverish, had a very bad headache and vomited, so that she went to bed. Her legs felt better, however. The next morning, July 16, she had less head- ache and felt pretty well. She stayed in bed, and at one o'clock took a little nap. When she awoke at two, she tried to get up and found she could not move her right leg. Except for inability to move her legs, she has felt perfectly well. On the afternoon of July 17 she was moved to Saint Luke's Hospital. At this time her neck was slightly stiff and movements were painful. She has had no headache and has not felt especially sleepy. She has not vomited since the onset. Her appetite has been poor. Urination has been normal. She has had no pains in her legs since the onset. Physical Examination. — The patient is a large, well developed girl. The skin is clear and not hot. There is rather marked brownish pigmentation all over the body, more especially over the lower part of the abdomen and upper thighs. Digitized by Microsoft® 132 A Clinical Study of Acute Poliomyelitis. The face is symmetrical. Eyes. — The eyes move normally. Pupillary reactions are normal. Ears. — No discharge, no tenderness over the mastoids. Mouth. — The tongue protrudes straight and has a slightly gray coat. The teeth are in good condition. The tonsils are somewhat enlarged and ragged, but there is no exudate. Throat is otherwise normal. Neck. — The isthmus of the thyroid is palpable. There is no stiffness of the neck. Superficial lymph nodes. — ^The lymphatic glands are not enlarged. Chest. — Well formed, symmetrical, both sides move equally with respiration, costal angle is ninety degrees. Heart. — Normal. Lungs. — Normal on auscultation and percussion. Abdomen. — Level, soft, tympanitic, no masses or tenderness. The abdominal wall moves normally with respiration. Abdominal reflexes are present. Liver. — Flatness extends from the sixth space to the costal margin. Edge is not felt. Spleen. — Just palpable on deep inspiration. Muscular system. — Legs: reflexes; Kernig's sign, knee jerks, Achilles, Babinski, and Oppenheim reflexes are absent on both sides. Movements of the legs : right leg, complete flaccid paralysis of all of the leg muscles, including the iliopsoas. Left leg, movements are all possible but rather weak. Patient states that it is more difficult for her to move her leg than it was yesterday. Weakness is especially marked in the quadriceps extensor. Sensation is normal on both sides. There is no pain or tenderness over either leg. Arms : muscular movements are strong on both sides. Temperature. — 99.8° F. July 19. Blood count : leukocytes, 13,000 ; differential count of 200 cells : polymorphonuclears, 59 per cent.; small mononuclears, 17.5 per cent.; large mononuclears, 17 per cent. ; transitionals, 4.5 per cent. ; eosinophiles, 1.5 per cent. ; mast cells, 0.5 per cent. Red cells are normal. Spinal fluid: 15 c.c. of clear colorless fluid, not opalescent; no increase of pressure; cell count, 297 per c.mm. ; smear, small mononuclears, 96 per cent.; large mononuclears, 4 per cent. ; globulin, + ; albumin, + ; sugar, +. July 22. 8 :oo P. M. Leukocytes, 10,400. The pain is extreme. The patient no longer has pain in the back, but has great pain all through the thigh, front and back, extending down into the calf. This is especially marked on the right (paralyzed) side. The leg is tender, and there is a spot of especial tenderness over the anterior crural nerve, just below Poupart's ligament. Heat is com- forting but does not relieve the pain. There is no pain in the head or stiffness of the neck. The ears and throat are negative. The heart is negative, lungs clear, abdomen soft, no tenderness. July 23. The patient was given morphia twice and had a fair night. This morning the pain is starting again. The pain and tenderness in the back are less. Left leg: knee jerk is absent, Achilles reflex active. There is no marked pain, but there is tenderness over the sciatic nerve. Right leg : there is pain in the upper and lower leg like a " tired feeling." There is exquisite tenderness on pressure over the course of the sciatic nerve in the posterior thigh, popliteal space, and calf region. Tenderness is fairly accurately localized over the nerve. There is extreme tenderness over the anterior crural nerve j ust below Poupart's ligament, over the upper front of the thigh, and over the inner aspect of the thigh. Heart, lungs, and abdomen are negative. July 28. Spinal fluid : 25 c.c. of perfectly clear fluid, not opalescent ; pressure increased; cell count, 38 per c.mm.; smear, mononuclears, 99 per cent.; endo- thelials, I per cent; globulin, ++ (heavy flocculent precipitate). Towards Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 133 evening the patient began to have considerable pain, after a very comfortable day. The pain was present over the left lower quadrant of the abdomen and especially over the left gluteal region and thigh. The upper border of quite a definite area of hyperesthesia is at the level of a line extending from the crest of the ileum to somewhat above the pubes. The lower line of the area of tender- ness and hyperesthesia on the thigh is less definite. There is marked pain on pressure over the outer left thigh and over the inner thigh below Poupart's liga- ment. Palpation of the abdomen is painful over the left lower quadrant. The abdomen moves well with respiration. There is no spasm, no mass. August 2. Spinal fluid: 15 c.c. of clear fluid; no pressure; no blood; cells, 26 per c.mm. ; smear showed about 100 per cent, small lymphocytes ; globulin, -|- + (heavy flocculent precipitate). August 3. Sensation for touch and temperature is normal. August 4. Blood count: leukocytes, 18,100; differential count of 200 cells: polymorphonuclears, 67.5 per cent. ; lymphocytes, 19.5 per cent. ; large mono- nuclears, 3.5 per cent. ; transitionals, 9 per cent. ; eosinophiles, i per cent. August 6. There is a general improvement but the patient still has consider- able pain and needs codeine and often morphine nearly every day. The pain is all through the back and legs, especially the right, and tenderness is most marked over the nerve trunks. There is no more return of function in the right leg. August 9. Spinal fluid : 25 c.c. of clear limpid fluid ; no increase of pressure ; no blood ; cell count, 7 per c.mm. ; all mononuclears ; smear, mononuclears, H — h ; globulin, + ± (heavy white flocculent precipitate) . October 5. The general condition is excellent. Legs: reflexes on the right are absent. On the left the knee jerk is practically absent and Achilles reflex just obtained. Sensation to touch and pain is normal on both sides. The temperature is somewhat higher on the surface of the left leg than on the right. The right calf measures 28 cm., the left 31 cm. The right thigh measures 47 cm., the left SI cm. Movements of the left leg are normal. Flexion of the right thigh on the pelvis is possible and patient also has some power of adduction of the thigh. Extension of the lower leg is not possible. She has very little power to flex the toes. She can stand on the right leg, if the knee is held stiff, and can walk a little in this way. The patient is transferred to the New York Orthopedic Hospital to have a brace fitted. CASE 7. James C, age, 18 months. Brooklyn, N. Y. Admitted, August i, 1911. Dis- charged, August 13, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat : the family lives in a four family house in the country. The house is eight years old. It is clean and has good air. There are no animals in the house. The mother states, however, that there are lots of bedbugs, cockroaches, and chicken lice. Past History. — Contains nothing of importance. Present Illness.— Th<: child was absolutely well until six days ago when, after a nap, he woke up suddenly, and his mother on trying to make him walk, found that he could not stand. He had been playing before that same morning. He vomited once two days later, the vomitus consisting of '' curds." He has been very restless but not drowsy. The mother noticed that he would "shake his arms and legs " three or four times during the night. He has sweat profusely Digitized by Microsoft® 134 A Clinical Study of Acuie Poliomyelitis. and has cried out with pain on being touched. His appetite has been poor, and he has had a bad cough since onset. He has also had difficulty in urination and has been very constipated. Four days ago the left arm became very weak, but it improved on being rubbed. The right arm also was weak two days ago and appeared to be painful. Physical Examination. — The patient is a rather thin, well developed baby, lips and skin pale. The skin is clear except for many small brownish papules the size of pinheads over the neck and shoulders (prickly heat?). The child lies quietly with his eyes closed, dozing, and objects to being touched. Anterior fontanelle not quite closed, frontal bosses prominent. Tache cerebrale is well marked but not of long duration. Eyes. — Pupils are equal, regular, and react normally. Ocular movements are normal, no strabismus. Ears. — No discharge, no tender- ness over mastoids^ Nose.— No discharge from nares, no excoriation. Face. — The face is symmetrical at rest, drawn more to the left than to the right on cry- ing. Mouth. — The tongue has a moderate grey coat and protrudes straight. The teeth are in fair condition. Tonsils are not enlarged; pillars slightly reddened, no exudate. Neck. — The neck is somewhat stiff and resists flexion. Superficial lymph nodes. — Small discrete glands felt in neck, axillae, and groins. Chest. — Well formed, symmetrical. Both sides move equally with respiration. Respira- tion is chiefly abdominal. Costal angle is ninety degrees. Heart. — Normal in size. Action is regular and rapid. Sounds are of good quality, no murmurs. Lungs. — Clear throughout on ausculation and percussion. Abdomen. — Level, soft, tympanitic, no masses or tenderness, symmetrical, moves normally with respiration. Abdominal reflexes are present. Liver.— FUtness extends from sixth rib to the costal margin. Edge is felt 3 cm. below the costal margin. Spleen.— Not felt. Muscular system.— Legs : all reflexes are absent on both sides. Kernig manipulation is painful on both sides. Movements : there is appar- ently a complete flaccid paralysis of both legs, including the iliopsoas. The only exception noted is power of flexion of the toes of the right foot and slight power of flexion on the left. Arms: movements are normal, but the right arm is weaker than the left. Neck and back muscles are weak. When the child sits up, the head drops forward, backward, or sideways. The spine is not held straight, but the buckling is not constantly towards one side. The back is not well supported from the hips. The child falls forward. August I. Blood count: leukocytes, 12,200; differential count of 200 cells: polymorphonuclears, 47 per cent.; small mononuclears, 40 per cent.; large mononuclears, 10 per cent.; transitionals, 2.5 per cent.; eosinophiles, 0.5 per cent; mast cells, o. Spinal fluid : 15 c.c. taken ; clear watery fluid, not opalescent ; no increase of pressure; cell count, 7 per c.mm.; smear, small mononuclears, 98 per cent.; large mononuclears, 2 per cent, (no blood) ; globulin, + + (heavy flocculent precipitate). August 13. The mother came and wanted to take the baby home. No im- provement has been noted in paralysis. He was discharged. CASE 8. Julia S., age, 2 years and 3 months. New York City. Admitted, September 29, 1911. Discharged, November 12, ipii. Result, improved. Diagnosis.- Acute poliomyelitis. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Bochez. 135 Family History. — Negative. Past History. — The patient has always been a healthy child. Present Illness. — On Tuesday, September 26, three days ago, the patient was perfectly well and happy. On Wednesday, September 27, she was feverish and lost her appetite. The mother said that she became very drowsy on that day. She did not vomit or cough. There were no convulsions but occasional twitch- ings of the legs and arms. The patient was constipated. Very little sweating occurred until after the doctor gave some powders to control the fever. Yes- terday the patient complained of pain in the neck. She has gradually become more and more stuporous until today she seems to recognize no one. Physical Examination. — The patient is a well nourished little girl, who lies apparently in coma vigil. For the most part the*'eye slits are held wide and the expressionless eyes are drawn usually to the right. She can be aroused by handling, and then she whines and Cries in an irritated way. She evidently sees, but does not recognize. When a strong light is thrown- in the eyes, she attempts to close the lids but does not succeed completely; a narrow slit remains. The eyeballs are rolled upwards synchronously, so that the pupils are covered by the upper lid. The head is held a little retracted and almost constantly on the right, although . free voluntary motion is possible in all directions. Occasionally a slight twitch or tremor passes over one extremity or side. At times she lowers the upper lids and dozes off into deep sleep. The face is a little flushed and the lips tinged faintly with cyanosis. She breaths a little more rapidly than is normal. Eyes. — Pupils are equal and react to light. Sometimes a fine nystagmus is seen when the eyes follow an object well to the side. Occasionally slight incoordina- tion of the eyeballs is seen. There is slight exophthalmos. Ears. — Normal. Nose. — No discharge. Mouth. — The tongue is heavily coated, and there is much thick greyish material posteriorly. The mucous membrane is reddened through- out, especially in the pharynx. The tonsils are very large and look almost in- flamed. Teeth are in fair condition. Superficial lymph nodes. — ^The posterior cervical, axillary, and inguinal nodes are palpable. The posterior cervical are enlarged. Neck. — The neck is markedly stiflf to flexion anteriorly, though the impression is gained that much of the resistance is voluntary and not reflex. The thyroid gland seems to be enlarged, especially the isthmus. Back. — Patient cannot be made to sit up because of resistance offered to flexing the spine. Thorax. — Well formed, moves properly in respiration. Lungs. — Clear. Heart. — Normal. Abdomen. — Soft, no tenderness, no masses. Spleen and liver are not felt. Extremities. — No weaknesses are found in either upper or lower. Ktiee jerks are obtained with difficulty on the right, absent on the left. Babinski reflex is absent. Kernig's sign: there is no resistance to complete extension of the leg on the flexed thigh. No complaint of pain on the right side, very slight objection at end of manipulation on the left. Achilles reflexes are slightly active on the right, absent on the left. Temperature. — 102.8° F. September 29. Spinal fluid : clear limpid fluid, pressure very slightly in- creased; cells, 113 per c.mm. ; polymorphonuclears, 30 per cent.; mononuclears, 83 per cent.; globulin, very slightly hazy (normal); sugar, -j-. Blood count: leukocytes, 14,200; diflferential count of 200 cells: polymorpho- nuclears, 58.5 per cent.; lymphocytes, 31.5 per cent.; large mononuclears', 7 per cent.; transitionals, 3 per cent.; basophiles, o; eosinophiles, o; stin»ulation form, o. Digitized by Microsoft® 136 A Clinical Study of Acute Poliomyelitis. September 30. General picture this morning is about the same. The child lies in a sort of stupor with eyes partly closed. She cries irritably on being aroused by prodding. There is no facial weakness, but the mask-like expres- sion is striking. There is complete flaccid paralysis of the left deltoid and biceps, and perhaps also of the triceps. The left quadriceps responds very slightly to the patellar tap. This was not noted yesterday, probably on account of incorrect observation. The diaphragm is working. There is possibly a little weakness of the right shoulder muscles. The temperature remains at 102.4° F. Tuberculin test (cutaneous) applied at 5 :20 p. m. October i. Von Pirquet reaction negative this morning. The child seems certainly no worse. There is no advance in paralyses. Spinal fluid: 17C.C. of very slightly turbid fluid, no increase of pressure; cells, 239 per cmm. ; polymorphonuclears, 4 per cent; mononuclears, 96 per cent.; globulin, very slightly + ; sugar, -1-- October 2. The patient continues to lie in a stuporous condition. There is definite paralysis of both deltoids this morning. The patient can move both legs, but the right less than the left. Knee jerk is absent on both sides this morning and the Achilles reflexes are also absent. The eyes show nystagmus easily and are still drawn chiefly to the right. The waxy or mask-like lack of facial expression continues. October 3. The child is brighter this morning, but still lies sleepily with the head on the right, and the eyes drawn to the right. She can move them incoordi- nately toward the left, but there is a definite paresis of the right internal and left external recti. The temperature has dropped rapidly in the past 36 hours. Spinal fluid : 25 c.c. of clear limpid fluid, pressure very slightly increased ; cells, 112 per cmm.; polymorphonuclears, 7 per cent. ; mononuclears, 93 per cent., globulin, very slightly + ; sugar, -|-- October 4. The patient talks this morning and answers questions intelligently. She lies still, however, with head and eyes drawn to the right. Sometimes one gets the impression that she does not see. The temperature curve continued downward yesterday to 96.8° F., but this morning it has risen to 100° F. and now is normal again. October 5. The child does not seem so well today. She lies more on her side with head retracted and drawn far to the right. The eyes also are still drawn to the right. She tries to avoid manipulation of the lower extremities. There is definite weakness, if not paralysis, of the quadriceps group of the right side. The leg cannot be extended on the thigh. October 6. The child lies on her side with back arched, legs extended, and neck retracted. She moans constantly when approached. The neck is resistant. The eyes are usually turned to the right. The child cannot be made to respond at all. The arms are apparently weak. There is paralysis of the flexors of the right thigh. The child looks decidedly sick and her appearance suggests meningitis. October 10. Spinal fluid: 20 c.c. of clear watery fluid, pressure slightly in- creased; cell count, S per cmm.; mononuclears, -f + ; globulin, slightly -|-; sugar, -f. Blood count: leukocytes, 11,200; differential count: polymorpho- nuclears, 52 per cent.; lymphocytes, 35.5 per cent.; large mononuclears, 7.5 per cent.; transitionals, 3 percent.; mast cells, 0; eosinophiles; 1.5 percent; stimula- tion form, o. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 137 October ii. The patient is brighter and notices her surroundings, but is still irritable. There is no advance in paralyses. There is definite power now in the right quadriceps. This represents either a return or possibly an error in the finding of October 5. October 12. Spinal fluid: 12 c.c. of clear limpid fluid; cells, 35 per c.mm.; mononuclears, + ; globulin, very slightly + ; sugar, +. October 14. The child is much brighter. She is slightly propped up on pillows this morning and looks about with considerable interest. October 20. Spinal fluid: clear colorless watery fluid, pressure not increased; cells, 12 per c.mm.; mononuclears, +; sugar, +; globulin, +. October 23. The patient continues to improve, but she is still a little irritable, and there is pain when the spine is flexed. The left knee jerk is present, the right very indefinite. There is good power in the left leg, much less in the right. CASE 9. Dora O., age, 4 years. New York City. Admitted, September 30, 191 1. Dis- charged, November 23, 1911. Result, improved. Diagnosis. — ^Acute poliomyelitis. Family History. — Negative. Past History. — The patient has always been well, though she has been a delicate child. Present Illness. — On Wednesday, September 27, three days ago, the child was perfectly well and cheerful. She seemed well on Thursday also, until evening, when she vomited. Later in the night she was put on the toilet, left alone for a few minutes, and fell to the floor. She was put to bed yesterday morning. At that time she could not stand, though she could move her legs. This morning the father noticed that the left lower extremity was much worse than the right. She has had no convulsion and has not had any noticeable sweating. Physical Examination. — ^The patient is a well nourished little girl who lies quietly and dozes when undisturbed. She objects to being handled and cries in an annoyed way on physical examination. Eyes. — Pupils are equal and react normally. Ocular motions are normal. Ears. — Normal Nose. — The right inferior turbinate is red and swollen. There is no discharge. Mouth. — Lips are dry. The buccal mucous membrane is red. Pharynx is somewhat reddened. Tonsils are not very large. The tongue is heavily coated with a whitish fur through which the red points of the papillae can be seen. Superficial lymph nodes. — The posterior cervical, axillary, and inguinal nodes are palpable. Neck. — The neck is stiff, attempts at flexion are resisted. The anterior muscles are not weak. Back. — The back is held rigid to prevent flexion. It hurts the patient to sit up. Thorax. — ^Well formed, respiratory movements are normal. Lungs. — Clear. Heart. — Somewhat rapid, otherwise normal. Abdomen. — Soft, not distended, no tenderness, no masses. Liver. — Not enlarged. Spleen. — Not enlarged. Extrem- ities. — Upper: no weaknesses found. Lower: there is general weakness or pos- sibly lack of willingness to move the right lower extremity. When prodded it is finally drawn up and moved in such a way that no definite paralyses can be made out. There is practically complete paralysis of the whole left lower extremity, except for power to flex the toes. There is also a little power left in the iliopsoas.' There is definite foot drop. Knee jerks are slightly active on the right (belly of vastus internus twitches), absent on the left. Achilles reflex is Digitized by Microsoft® 138 A Clinical Study of Acute Poliomyelitis. active on the right, and absent on the left. Babinski test gives plantar flexion on both sides. Kernig's sign: there is practically no resistance of a spasmodic nature on either side. Marked pain is caused on both sides by the manipulation, especially towards the end. Temperature. — 102.4° F. September 30. Spinal fluid: 25 c.c. of clear fluid, pressure not increased; cells, 133 per c.mm. ; polymorphonuclears, 6 per cent. ; mononuclears, 94 per cent. ; globulin, o; sugar, slightly +. Blood count: leukocytes, 20,000; differential count of 200 cells : polymorphonuclears, 49 per cent. ; lymphocytes, 25 per cent. ; large mononuclears, 26 per cent.; transitionals, 8 per cent.; basophiles, o; eosinophiles, i per cent.; stimulation form, o. Temperature. — 101° F. October 6. The temperature is normal. The child is very bright and lively, laughing and playing. Both legs are very tender to pressure and painful on movement. There is distinct tenderness below Poupart's ligament. The pain is so great that she can scarcely be induced to try to move the legs. The right leg does not seem to be paralyzed, but she will only move it a little. The left leg seems paralyzed except for the flexors of the toes. October 19. The child is rather hysterical, laughs too easily and cries too easily. There is no improvement in paralysis of the lower extremities. Spinal fluid : clear colorless watery fluid, no increased pressure ; cells, 3 per c.mm.; mononuclears, +; globulin, slightly +'; sugar, +. October 24. The pain is less and the nervousness is less marked. There is no return of motion in the left leg. The quadriceps on the right is paralyzed. October 30. The child still has pain on movement of the left leg and foot. There is no retrogression of the paralysis of the left leg. The psychic condition is about the same. She laughs hysterically and changes quickly from laughter to crying. November 6. Spinal fluid: clear, colorless, and watery; pressure not in- creased; cells, 3 per c.mm.; mononuclears, + ; globulin, normal; sugar, +. November 7. The patient is in much better general condition. There is no improvement in paralysis of the left lower extremity. The right lower extremity has apparently regained complete power. CASE 10. Americo B., age, 2 years. West New Rochelle, N. Y. Admitted, October 6, 1911. Discharged, October 29, 1911. Result, improved. Diagnosis.— Acuit poliomyelitis. Family History. — Negative. Past History.— The child has always been perfectly well. Present Illness.— On Sunday, October i, five days ago, the child seemed not quite so well as usual and vomited twice. The next day he was feverish and stayed m bed. Since that time he has been in bed. Four or five days ago when he had the fever, he also had slight convulsions. He has not cried much and has had no cough. Bowels and urination have been normal. He has been very sleepy. Has eaten well. Patient has not seemed very tender until today when he has objected to being handled. Yesterday morning it was noticed that he could not move the left arm, which seemed tender. The other limbs have moved normally. Physical Examination.— The patient is a well built, strong looking child, Digitized by Microsoft® Francis W. Peahody, George Draper, and A. R. Dochez. 139 lying on his back. He is quiet, does not cry, and is quite dull. He cannot be made to take an interest in anything. The skin is cool and rather dry. There is no rash. Eyes.— Pupils are small, equal, regular, and react to light. There is no strabismus. Ears. — No discharge or tenderness over mastoids. Nose. — No discharge or excoriation. Mouth.— Tht lips are dry, the tongue slightly coated. Teeth are dry and in good condition. Tonsils are slightly enlarged, not reddened. Neck. — The neck is stiff and resists flexion but is not retracted. Superficial lymph nodes. — Small glands are felt in the neck, axillae, and groins. Chest.— Well formed, moves normally with respiration. Respiration is chiefly abdominal in type. There is no marked rosary. Lungs. — Clear on auscultation and percus- sion. Heart. — Not enlarged, action regular, sounds of good quality, no murmurs heard. Abdomen. — Slightly distended, soft, tympanitic, no masses or tenderness found. Abdomen moves normally with respiration. Abdominal reflexes are present. There is moderate tache cerebrale. Liver. — Flatness extends from the sixth space to the costal margin. Edge is not felt. Spleen. — Not felt. Extrem- ities. — Upper : the right arm is normal. Left arm : movements of the fingers, flexion and extension of elbow are normal, but a little weak. There is appar- ently paralysis of the shoulder muscles, but the child is so drowsy that it is impossible to determine of which ones. Movement of the left arm is somewliat painful. Lower: movements are normal on both sides. Knee jerks are active on both sides. There is no Babinski reflex. Attempt to elicit the Kernig reflex on both sides causes pain, but no especial spasm. The child can support the head when sitting up. Temperature. — 99° F. October 7. Spinal fluid : 15 c.c. of clear watery fluid, pressure not increased ; cell count, 12 per c.mm. ; mononuclears, -h + ; globulin, slightly -|- ; sugar, -1-. Blood count : leukocytes, 9,800 ; differential count of 200 cells : polymorpho- nuclears, 64.5 per cent. ; lymphocytes, 21.5 per cent. ; large mononuclears, 7 per cent. ; transitionals, 3.5 per cent. ; mast cells, i per cent. ; eosinophiles, i per cent. ; stimulation forms, 1.5 per cent. October 8. The child is still rather dull and pays no attention to anyone, but he is not at all comatose. The right arm moves normally. The left is paralyzed, apparently only in the shoulder. The legs are held stiff, flexed at the knees and thighs. They are not paralyzed, but all motion of the legs, and especially extension, is resisted as if painful. The right knee jerk is not obtained. The right Achilles reflex is barely obtainable. The left knee jerk is just present, left Achilles reflex is normal. There is no hyperesthesia to pres- sure. October 14. The child remains in about the same condition, fairly bright, but rather irritable and whining. There is no change in the paralyses, the left upper arm only is affected. Movements and reflexes of the legs are present. There, is pain on flexion of the neck, and there is resistance to flexion. There is also pain in the legs. When one attempts to handle the legs, the child flexes them sharply at the knee and resists strongly all attempts to straighten the leg, even attempts to straighten the leg when the hip is not flexed. There is no defi- nite pain on pressure. October 19. The patient is much less irritable. He can sit up alone and walk. He apparently has plenty of strength in the legs, but his sense of equilibrium is faulty. The paralysis of the left arm remains unchanged. Digitized by Microsoft® 140 A Clinical Study of Acute Poliomyelitis. CASE II. Moses F., age, 20 months. Brooklyn, N. Y. Admitted, September 18, 1911. Discharged, November 12, 1911. Result, improved. Dtogwojw.— Acute polio- myelitis. Family History. — Negative. Habitat: the family lives at Varrett Street, Brooklyn, in a house in which there are two families on a floor. There are seven other children on the same floor. Two months ago, a family with sick children had been dispossessed in this house. The nature of the sickness of those chil- dren is unknown. There are no pet animals in the family, but the usual para- sites. The child had never been out of the city of Brooklyn. Past History. — The child has always been strong and healthy, except that, according to the mother, he had pneumonia two weeks ago. Present Illness.— FriAzy, September 8, ten days ago, he was perfectly well. On Saturday, September 9, the mother noticed a fever, which continued for the next eight days. The child vomited after taking medicine in the second week. Thursday, September 14, there were some choreic motions of the hands and head. On that evening, he could not move his right hand. The next morning he could not move the other hand. There was no weakness. The child has been irritable and crying and has not slept well. He complains of pain when handled. The bowels have been constipated but moved by enema. Physical Examination. — The child lies comfortably on his back. He seems fairly bright and responds readily to stimulation. He is irritable on being handled. His legs are drawn up. At times the child has a loose cough. The head is well formed and the fontanelles are closed. Eyes. — There is no ptosis. The sclerse and conjunctiva are clear. The pupils are not dilated, and both react to light, but the left pupil is slightly larger than the right. Ears. — There is no mastoid tenderness. Nose. — There is no discharge. Mouth. — The lips and mucous membranes are of good color. The tongue is red, moist, and has no coat. The pharynx is injected. The tonsils are visible but not large, and there is no exudate. Neck. — The anterior muscles seem weak. He holds his head erect, biit it is unsteady, with a tendency to drop back. There is no retraction of the neck. There is marked overaction of the sternomastoids which apparently support the entire weight of the head. Superficial lymph nodes. — The glands in the right posterior triangle are palpable. The left axillary and both inguinal groups of glands are palpable and shotty. Chest. — It is well formed, symmetrical. The breathing is entirely costal in type. Expansion is fair, and slightly more on the left than on the right. The ribs move well. The accessory muscles of respira- tion are not brought into play. There is no apparent descent of the diaphragm. There is retraction of the abdomen on inspiration. Lungs. — The right side is resonant in front and back on percussion. Percussion note in upper front oil left side is high pitched, in lower axilla and back it is somewhat flattened. The,right side is clear on auscultation. No rales are heard over the area of impaired resonance on the left. The breafh sounds over this area are somewhat more distinct than over the corresponding area on the right side. The quality, how- ever, is normal. Heart. — Negative. Pulse. — Regular, quality good. Abdomen. — It is retracted on inspiration. There is no descent of the diaphragm. Abdomen is soft, no masses or tenderness. Superficial reflexes are weak, but present on both sides. The testicular reflex is active. Extremities. — Arms : complete Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 141 flaccid paralysis of whole right arm. Complete flaccid paralysis of left upper arm and shoulder muscles. Extension of the wrist and fingers is somewhat stronger than flexion. Brachial reflex absent on both sides. Legs : strong and can be moved in all directions. -The knee jerks are active on both sides. Achilles reflexes are not obtained, Babinski reflexes are absent. Kernig's sign is absent. Temperature. — 98.8° F. September 18. Spinal fluid: 30 c.c. of clear limpid fluid; cells, 8 per c.mm.; globulin, very slightly +; sugar, +. Blood count: leukocytes, 20,100; differ- ential count of 200 cells: polymorphonuclears, 45 per cent.; lymphocytes, 40.5 per cent.; large mononuclears, o; transitionals, 9.5 per cent.; basophiles, i per cent.; eosinophiles, 3.5 per cent. ; stimulation form, 0.5 per cent. , September 20. Percussion of lower left lung is unchanged. No rales are heard. The paralysis remains the same. The breathing is purely costal in type. The intercostals are strong. September 25. Spinal fluid: 24 c.c. of slightly blood-tinged fluid;. the specimen for the tests is clear; cells, 4 per c.mm.; globulin, very slightly + ; sugar, +. Blood count: leukocytes, 25,600; differential count of 200 cells: polymorpho- nuclears, 59 per cent.; lymphocytes, 33.5 per cent.; large mononuclears, o; transi- tionals, 7.5 per cent.; basophiles, o; eosinophiles, o; stimulation form, o. September 30. The diaphragm still does not act, but the patient seems per- fectly comfortable with the intercostals acting alone. October 2. Spinal fluid : 18 c.c. of clear fluid ; cells, 3 per c.mm. ; globulin, ; sugar, -t-. October 24. For the past week the patient has been walking alone. He carries his head far forward with his face a little down, so that he looks up under his eyebrow to see where he is going. The head is held also a little to the right. The trapezius seems to be doing all the work of holding the head up. This gives a peculiar sloping line from head to shoulder and makes the neck look very short and thick. There is no return of power in the arms. October 30. The child is improving somewhat. He walks very well. He still holds his head tilted to the right. He tries to use his hands and can now pick up objects from, the floor with his left hand, but there is little improvement in the arms. November 12. The child is in excellent general condition. The heart, lungs, and abdomen are clear. The child walks very well and can even run a little. The pupils are equal, regular, and react normally. The neck, back, and abdominal muscles are strong. There is apparently some overdevelopment of the trapezius which supports the head The pectorals are atrophied. There is a large fold of fat just inside the axillae, over the pectorals, and a heavy collar of fat around the neck. The legs move normally. Both knee jerks are exaggerated. There is no true ankle clonus. No Babinski or Kernig's signs. The cremasteric and abdom- inal reflexes are present. The right arm and hand are completely paralyzed from shoulder to fingers. The left shoulder and apparently the extensors of the hand are paralyzed. The only movements possible are flexion and extension of the thumb. He has a remarkably strong grip with the left hand. CASE 12. John B., age, 3 years. New York City. Admitted, July 18, 1911. Discharged, August 20, 191 1. Result, improved. Diagnosis.— ^cMtt poliomyelitis. Digitized by Microsoft® 142 A Clinical Study of Acute Poliomyelitis. Family History.— Hegativt. Habitat: the family lives in a sixteen family tenement. The home is clean and has plenty of air. As far as is known, there are no sick children in the house, and the child has come in contact with no one who is lame or paralyzed. Past History. — He has always been well except for two attacks of measles, the last one a year ago. Present Illness.— Two days ago, on July i6, the child was perfectly well. He usually takes a nap in the afternoon, but on this day he went to sleep in the morning. When he woke up at noon, he started to play, and one of the other children noticed that he could not lift his hand. However, in the afternoon he was well enough to play. He did not complain of pain, has not vomited, has not sweat, and has not been feverish. He has not been especially restless. Yesterday he was playing but could not use his arm. He has had no headache. Appetite has been poor. Bowels and urination normal. The arm has not become any worse. Face has been unaffected. Physical Examination.— The patient is a well built little boy lying quietly half asleep. He takes little notice of his surroundings and is not easy to rouse. The skin and mucous membranes are of good color. Eyes. — The eyes move normally. The right pupil is larger than the left. The right pupil reacts to the light but the left apparently does not. Ears. — Normal. There is no discharge and no tender- ness over the mastoids. Mouth. — The tongue has a grey coat and protrudes to the right. The teeth are in good condition. The tonsils are enlarged and ragged. There is no exudate, and they are not reddened. Superficial lymph nodes. — There are small lymphatic glands palpable in the neck, axillae, and groins. Chest. — Well formed, symmetrical, and both sides move equally. Heart. — Normal. Lungs. — Normal on auscultation and percussion. Abdomen. — Full, soft, tympanitic throughout. It is symmetrical and moves normally with respira- tion. There are no masses or tenderness. Liver flatness extends from the sixth rib to the costal margin. Edge is felt 2 cm. below the costal margin. Spleen is not felt. Abdominal reflexes are not obtained. Muscular system. — Legs : knee jerks and Achilles reflexes are present on both sides. The other reflexes are negative. Movement of the legs : there is apparently no paralysis or weakness of either leg. Arms : the muscles of the right arm seem to be unaffected. There is a complete flaccid paralysis of the left arm and hand. The child does not move the arm or hand, and when lifted, it falls limply. Muscles of the back : there is no stiffness of the neck. Child sits up well and holds up its head. Face.— The right side of the face is slightly more flattened than the left. The folds of the skin are less marked on the right. The left corner of the mouth is drawn up slightly, and this becomes more marked when the child cries. The right eye slit is narrower than the left. There is apparently no weakness of the right upper lid as this can be raised normally. Surface.— Thtrt is a small area of herpetic eruption on the upper lip just to the left of the median line. July 18. Blood count: leukocytes, 15,100; differential count of 200 ceils: polymorphonuclears, 55 per cent. ; small mononuclears, 26 per cent. ; large mono- nuclears, 8.5 per cent.; transitionals, 1.5 per cent.; eosinophiles, 9 per cent. Red cells normal ; blood platelets normal. July 19. Spinal fluid: 20 c.c. of perfectly clear colorless fluid; pressure not increased; cell count, 37 per c.mm.; globulin, slightly opalescent, slightly +; Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Bochez. 143 albumen, slightly + ; sugar, + ; smear, small mononuclears, 88 per cent. ; large mononuclears, lo per cent. ; polymorphonuclears, 2 per cent. ; a few red cells. July 21. Left arm : it is difficult to make the child attempt movements, but this morning he can extend his fingers, flex the fingers slightly, and flex and extend the thumb. The child complains of pain in the legs, but reflexes and movements are normal. July 23. The left pupil reacts normally. July 25. Spinal fluid: 15 c.c. of perfectly clear watery fluid; not opalescent ; no increase of pressure ; cell count, 12 per c.mm. ; smear, chiefly small mononuclears, too few to count; globulin, slightly +. July 27. There is still very slight evidence of right-sided facial paralysis. , The left eye slit is slightly narrower than the right. When seen this morning the child was sweating profusely about the head. The sweating was much more intense on the right side of the head, face, and forehead. Both pupils react normally to light. There is no more paralysis of dilation of the pupil. The tongue protrudes straight. July 31. The knee jerk is active on both sides. There is hemicranial sweating. Sweating on the right side of the face is frequently observed, while the left side is practically without sweat. The left eye slit is narrower than the right. The right side of the face has a better pink color than the left. The pupils are equal, regular, and react normally. August 20. His general condition is very good. The chest and abdomen are negative. The legs move normally. The reflexes are normal. The left eye slit is slightly narrower than the right (the lid is a little swollen). The pupils are equal, regular, and react normally. The eyes move normally. The right arm is normal. Left arm : there is complete paralysis of the shoulder muscles and of the flexors of the elbow. The child seems able to use the triceps to extend the elbow. Extensors of the hand are strong, flexors of the fingers and muscles of the thumb are weak but act fairly well. The child has had no hemicranial sweating or flushing of late. He is discharged. CASE 13. Victoria M., age, 4 years. Sandy Hook, N. J. Admitted, July 15, 1911. Dis- charged, September 9, 1911. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat : the family lives in a large house at Sandy Hook. There are three families in the house, but each has a separate entrance. The house is twelve years old and clean. There are no other children in the house. There is no one lame or paralyzed in the vicinity. The children have not been away from Sandy Hook since last October, and neither children nor parents have come in contact with anyone who is lame or paralyzed. Past History. — The child was a normal baby. She is thought to have had scarlet fever four months ago, but the diagnosis is uncertain. Present Illness. — On June 13 the child complained of pain in the stomach and vomited twice. She was very restless, slept poorly, and sweat a great deal, espe- cially around the head. For the next two weeks she was in bed about half the time and was in poor health. She was slightly feverish and dull. She com- plained of no pain except in the stomach. On June 23 she complained of pain in her right foot and her mother noticed that when she got up in the morning she Digitized by Microsoft® 144 A Clinical Study of Acute Poliomyelitis. limped and could not use her legs well. In the afternoon it was seen that she did not use her hands normally. The next morning she was taken to the Presbyterian Hospital. About a week before the onset of the paralysis, the mother noticed that while she was sleeping, her breathing was not like that of the other children. When breathing, her chest moved much more than normally, and her abdomen moved much less. Physical Examination. — The patient is a fairly well built little girl, lying on her back. The skin is clear. Eyes. — The eyes move normally, and the pupils react normally. Ears. — Normal, no discharge. No tenderness over the mastoids. Mouth. — The tongue is clean. The tonsils are somewhat enlarged; the throat is clean. Superficial lymph nodes. — There are small glands in the neck, axillae, and groins. Chest. — Respiration is very irregular and labored. After one or two shallow, quiet respirations, the child takes a deep forced inspiration which is associated with dilatation of the alae nasi. There is marked retraction of the abdomen and flaring of the ribs. With each respiration, the sternomastoid muscles become very tense, and the front of the chest is raised to a marked degree. The left side of the chest is more prominent than the right. Respiration is for the most part of a very jerky character and is at times like hiccough. This is, however, much diminished when the child is lying quietly and has stopped sobbing. Heart. — Negative. Lungs. — Normal throughout on auscultation and percussion. Abdo- men. — Level, soft, tympanitic, no masses or tenderness. At times, especially on expiration, there is marked bulging of the left upper quadrant. Abdominal re- flexes are not obtained. Liver. — Flatness extends from the sixth intercostal space to the costal margin. Edge is not felt. Spleen. — Not felt. Muscular System. — Legs : knee jerks, Babinski and Oppenheim reflexes are absent on both sides. Achilles reflex is barely obtainable on both sides. Extension of the legs causes marked pain so that Kernig's sign cannot be tested. Movements : flexion of the thighs is possible. There is toe drop and apparently paralysis of the quadriceps and the anterior tibial muscles. Posterior tibial muscles on both sides are unaffected. Movements of the arms are normal. The head flexes without pain. The child can sit up and hold her head up but is apparently rather weak. She complains of pain in both thighs. Temperature. — ioo° F. July 16. The child breathes quietly when let alone, but inspiration is always associated with retraction of the abdomen. On expiration there is bulging of the upper half of the abdomen. The muscular tone is good. July 18. The nurse noticed yesterday that the patient was unable to hold a piece of bread well in her hands. Arms : movements of upper arms, and flexion and extension of forearm are normal. Dorsal extension of hand at wrist is impossible on both sides. Flexion of the fingers is fairly complete but weak on both sides. July 19. The right side of the face shows some flattening, and the left corner of the mouth is drawn up. The left eye slit is narrower than the right. The tongue protrudes straight. The voice is very harsh, squeaky, and high pitched. July 23. The chest and abdomen are clear. Paralysis of the diaphragm persists. July 25. Spinal fluid : 18 c.c. of clear watery fluid, not opalescent ; no increase of pressure; partly bloody ; cell count, 165 per c.mm.; smear, small mononuclears, Digitized by Microsoft® Francis W. Peaiody, George Draper, and A. B. Dochez. 145 87 per cent.; large mononuclears, 9 per cent.; polymorphonuclears, 4 per cent.; globulin, slightly +. July 31. Spinal fluid : a few cubic centimeters of perfectly clear colorless fluid; no opalescence; no increase of pressure; cell count, 979 per c.mm. ; many large phagocytic cells ; smear, small mononuclears, 68 per cent. ; large mono- nuclears, 16 per cent; endothelial cells, 16 per cent.; no polymorphonuclears; many degenerated cells in the smear, apparently endothelial cells; globulin, slightly +. Temperature, 100° F. August 2. Spinal fluid: 10 c.c. of perfectly clear watery fluid; no opales- cence; pressure very low; cell count, 154 per c.mm.; a few phagocytic cells; smear, small mononuclears, 96 per cent. ; large mononuclears, 4 per cent. ; no blood; globulin, slightly +, opalescent; few small flocculi. August 5. There is gradual increase of power in the quadriceps on both sides. Both knee jerks were elicited this morning, the left being more active. August 8. Spinal fluid: 8 c.c. of clear watery fluid; pressure too low to measure ; cell count, 31 per c.mm. ; smear, large percentage of mononuclears ; globulin, very slightly -|-, slightly turbid, within normal limits; sugar, +. August 15. The diaphragm is now acting absolutely normally. The abdominal muscles act normally, and the reflexes are normal. Both knee jerks and both Achilles reflexes are obtained normally, there is no ankle clonus. The move- ments of both legs are normal, and fairly strong. She is walking and gets along well. The muscles of the neck are still weak (?), the head tends to fall back- wards. The extensors of the hand and muscles of the thumb show little improvement. CASE 14. Gladys B., age, 6 months. New York City. Admitted, October 27, 191 1. Discharged, November 11, 1911. Result, improved. Diagnosis. — Acute polio- myelitis. Family History. — Negative. Habitat: the family lives in a tenement. There are eighteen families in the building. The building is not old, and it is very airy and clean. There are no cats or dogs in the home; occasionally there are cockroaches. Max G. (a cousin of this child, and now in this hospital with poliomyelitis) lives on the ground floor of this building. There is very close contact between these two families, and Max plays continually with the B. children. On Tuesday, October 17, when Max was sick in bed, the baby was brought in and laid on a pillow on his bed. Shortly after that. Max was taken to the hospital. Since that time Gladys has not been in the G. home. Past History. — Negative. Present Illness. — On the morning of Saturday, October 21, six days ago, the baby was perfectly well when bathed. In the afternoon she vomited twice and had " high fever." The doctor thought it was angina and middle ear trouble. The next day she was feverish and very sick. There has been no vomiting since the first day of her illness. She has had no convulsions and has not sweat at all. Her bowels have been constipated. Urination has been normal. During her ill- ness the child has taken no interest in anything, and has slept most of the time. She has wanted to lie quietly in bed, and apparently has objected to being handled. She has taken her nourishment well. Two days ago, October 25, the mother noticed that the child did not use her left hand. Even the day before. Digitized by Microsoft® 146 A Clinical Study of Acute Poliomyelitis. the mother noticed that the child did not use her hands or her feet much. Yester- day she could move only the fingers of the right hand. The left arm and right leg were also paralyzed. The child looks brighter today and has less fever. Physical Examination. — The patient is a well built and strong looking baby. Sensorium is clear. The neck resists flexion. There is no retraction. The skin is clear except for a little scaling on the upper lip. The anterior fontanelle is open, but not bulging. The face is symmetrical. Eyes. — Pupils are equal, regular, and react to light. Ocular movements are normal. There is no strabismus or nystagmus. Ears. — There is no discharge or tenderness. Mouth. — Tongue is clean. Tonsils are slightly enlarged and rather ragged. There is no redness. Pharynx is normal. Superficial lymph nodes. — Glands in the neck are palpable. Chest. — The chest is symmetrical and moves well with respiration, but with in- spiration there is a very definite retraction and descent of the anterior chest wall. This is associated with a marked raising of the abdominal wall on inspiration. There is no special activity of the accessory muscles of respiration. Respiration is rapid, but not labored. Pressure over the abdomen causes great distress, but pressure over the chest does not affect respiration. Heart. — Normal in size. Regular. Sounds are of good quality. Lungs. — Qear on auscultation and percussion, except for a few scattered moist rales in both backs. Abdomen. — Full, soft, and tympanitic. There are no masses or tenderness. Abdominal reflexes are present. When the child sits up the abdominal muscles seem to lack tone. There is definite tache cerebrale. Liver.^Nonna.1 area of flatness. Edge not felt. Spleen. — Not felt. Extremities. — Right arm appears normal. Left arm : flexion and extension of fingers and wrists are normal ; flexion and extension of the elbow are weak, and it is difficult to determine whether or not it is completely paralyzed. Lower extremities : right leg is para- lyzed completely, except for the extensors of the toes and foot (anterior tibial and peroneal). In the left leg there is weakness of the quadriceps. Knee jerks, Achilles and Babinski reflexes are absent. Kernig's manipulation produces pain on the right, but not on the left side. Temperature. — 99° F. October 27. Spinal fluid: IS c.c. of clear limpid fluid; pressure not increased ; cells, 25 per c.mm. ; mononuclears, -|- + ; globulin, normal ; sugar, ■-!-. October 31. Paralysis of the intercostal muscles persists. There are no rales in the lungs. The general condition is excellent. Spinal fluid : 15 c.c. of clear watery fluid ; pressure slightly increased ; cells, 5 per c.mm. ; mononuclears, -|- ; sugar, -|- ; globulin, -|-'. November 6. Spinal fluid is clear, colorless, and watery; cells, 5 per c.mm.; mononuclears, -f ; globulin, very slightly -|- ; sugar, +. November 11. The child is in good condition. He has had a loose cough for some time and this persists slightly. The chest and abdomen are clear. His respiration is entirely abdominal. There is still some retraction of the thorax on inspiration, but it is not so marked as on admission. Paralysis of the inter- costals persists. Both hands, the lower arms, and the elbows move normally. There is weakness of the shoulders, especially of the deltoids. The arms can only be raised incompletely, but still there is very good motion in every direc- tion. The legs move normally. The knee jerks are both present. Achilles reflexes are not obtained. There is no Kernig's sign or Babinski reflex. The abdominal reflexes are normal. The residual paralysis consists of weakness of both shoulders and intercostals. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. 147 CASE IS. Louis G., age, 3 years. New York City. Admitted, July 31, 1911. Discharged, September 3, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History.— Negative. Habitat : the family live in a tenement with nine- teen other families. The house is not very old, is fairly clean, and has good air. There are no bedbugs or other parasites found in the home, and no dogs or cats belong to the family. They know of no other sickness in the house or neighbor- hood and of no lame or paralyzed children or any possibility of contact. Past History. — The child was always a healthy baby, nursed for eighteen months. He had a " convulsion " about every six weeks " when the teeth came out," but he has had none for the past six months. Six months ago he had measles, followed by whooping cough, the latter lasting five or six weeks. Present Illness. — ^Two weeks ago yesterday, July 16, the child was well in the morning. At one o'clock in the afternoon the father found him very feverish, and sent for a doctor. The next day the child was worse, and still feverish. He had no convulsions, no vomiting, and no cough, but was very restless and sweat a great deal. His appetite was poor. After three days the child got better, but stayed in bed because his neck was weak, and he could not hold up his head. Eight days ago, July 23, the father says that he complained of pain in the left foot, and it was noticed that he could not move either foot. Since the first three days he has had no fever. For the past eight or nine days he has had a little cough, but no expectoration. The bowels have been constipated and appetite very poor. The arms have not been affected. The child has had no trouble with respiration, and was doing well until yesterday afternoon at three o'clock, when the parents noticed that he was having diificulty in breathing. Respiration was rapid and associated with much movement of the belly wall. Since then he has become much weaker, has not slept, and has eaten very little. He has had more cough and has cried all night. He has not seemed to have pain or tenderness since the onset, when he had pain in the neck and foot. Physical Examination. — The patient is a well developed, very sick looking little boy. Sensorium seems clear. The lips are pale and have dry crusts on them ; no herpes. The skin is hot and dry and rather grey. On the chin are two pinhead sized petechial spots, no rash, no bites. The head is well shaped and the face symmetrical. Child swallows milk well. Eyes. — Movements are normal, no strabismus. Pupils are equal, regular, about 4 mm. in diameter. They con- tract in bright light, but do not dilate well. -The right eye slit is a trifle narrower than the left. On looking downward the sclera is seen above the left cornea. Ears. — No discharge or tenderness. Nose. — No discharge. Mouth. — The teeth are in good condition. Tongue protrudes straight, and has a thick grey coat. The tonsils are much enlarged, and rather ragged. No redness or exudate. Neck. — The neck resists flexion and there is slight retraction. Super- ficial lymph nodes.— The glands are not especially enlarged, but there are a few small ones in the neck and groins. Chest. — Symmetrical, well formed, costal angle is wide. Respiration is rapid. The neck muscles come into play actively, the sternomastoids stand out with each inspiration, and the alse nasi dilate with respiration. Respiration is wholly of the abdominal type. The chest hardly moves at all with respiration, the only movement being a retraction of the lower ribs and of the lower intercostal spaces on inspiration. The abdominal Digitized by Microsoft® 148 A Clinical Study of Acute Poliomyelitis. wall bulges forward on inspiration, and is retracted on expiration. Breathing is rapid and jerky, expiration is forcible. The expiratory sounds follow the retraction of the abdomen at a considerable interval. Heart. — Not enlarged, sounds obscured by rales, sounds of embryonic type. Lungs. — No dullness, no pure bronchial breathing, but both lungs are everywhere full of coarse moist rales. Respiration is harsh and loud. Abdomen. — Full, soft, tympanitic, no masses or tenderness. The left side is fuller than the right. Abdominal walls are very lax and bulge forward with inspiration. There is apparently a paralysis of the muscles of the abdominal wall. Abdominal reflexes are not obtained. Liver. — Flatness extends from the sixth rib to the costal margin, edge not felt. Spleen. — Not felt. Muscular system. — The arms move normally but there is apparently slight weakness of the right. Both legs lie limply on the bed and the child neither moves them nor resists passive motion. Movement of the flexors of the toes on the right is noted on plantar stimulation, but otherwise the legs are paralyzed. Knee jerks, Achilles, Babinski, Oppenheim, and Kernig reflexes are absent on both sides. The attempt to elicit the Kernig's sign is painful. It is impossible to determine about the back muscles, but they seem quite strong as the child is made to sit up. The child can hold his head up, but with difficulty. No pain or hyperesthesia is apparent except on attempting to flex the neck and in trying to elicit Kernig's sign. The child is very sick and it is impossible to determine the limits of paralysis accurately. July 31. Blood count: leukocytes, 19,700; differential count of 200 cells; polymorphonuclears, 84 per cent. ; small mononuclears, 6.5 per cent. ; large mononuclears, 6.5 per cent. ; transitionals, 3 per cent. ; mast cells, o ; eosino- philes, o. August 4. Spinal fluid: 20 c.c. of perfectly clear watery fluid, not opalescent; pressure loo-iio mm.; cell count, 29 per c.mm. ; differential wet count: 98 per cent, mononuclears; 2 per cent, polymorphonuclears; globulin, +' (flocculent precipitate). August 5. The chest is more free of rales. All the reflexes of the legs are still absent. August 8. The chest is practically clear of rales. The abdominal and back muscles are strong. The neck muscles are apparently strong, but on sitting up the child has a tendency to let his head hang backwards. August 19. The chest is clear. The child cries as soon as anyone tries to touch him or move his legs. He seems to have a good deal of tenderness still. The legs are the same as yesterday. Both knee jerks and Achilles reflexes are absent. September 3. The child is very bright and active. He is able to sit up alone. The movements of the head and neck are good. The abdominal reflexes are active, and there is no sagging of the abdominal walls when the child sits erect. The spine does not deviate to either side. The knee jerks are absent on both sides ; Achilles reflexes are absent ; there is no ankle clonus, but strong plantar flexion of toes on the left on plantar stimulation, and wink-like response on right. Movements of the right leg are absent below the hip. The left thigh can be weakly flexed, extended, and rotated outward. There is no apparent power of abduction. Flexion and extension of the right lower leg are absent, the left lower leg can be rather strongly flexed and extension of the foot is good. The Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. DocJiez. 149 toes on the left side can be both flexed and extended. The ribs move well on respiration, slightly more on the left than on the right side. The patient goes home today. CASE i6. Hyman W., age, 21 months. Brooklyn, N. Y. Admitted, September 22, 1911. Discharged, November 26, 191 1. Result, improved. Diagnosis. — Acute polio- myelitis and acute bronchitis. Family History. — Negative. Habitat : the family lives in a four family house on Willoughby Avenue, Brooklyn. They have four rooms on the first floor The light in the bedrooms is bad, in the other rooms it is fair. There is no similar illness in the house. The child has played with other children of the street and house. There are flies and mosquitoes in the house, no roaches or waterbugs, but some bedbugs. Past History. — The patient has always been a healthy child. Present Illness. — On Sunday morning, October 15, five days ago, the child was perfectly well. In the afternoon he had two attacks of vomiting. The next morning, Monday, he had a temperature of 103-104° F., but was up and walked about during the day. On Tuesday, two days after the onset, paralysis of both legs was noticed and weakness of the right arm. On Wednesday, the child had some difficulty in swallowing. He has had no dyspnea or convulsions. Child has not been very irritable. For two days he has had pain when the head was raised, and on sitting up the head dropped backward. There has been no rigidity or retraction of the neck. He has had no discharge from the ears, no cough. Bowels moved last on Wednesday after enema and castor oil. There has been no retention of urine. Physical Examination. — The child lies quietly in bed sleeping. On being awakened he responds slowly to stimulation and is drowsy and dull. He cries weakly on being handled. The skin is moist and warm. There is a slight degree of dyspnea. Head. — Well formed, slight frontal prominence. Fontanelles are closed. Face. — Symmetrical in repose, drawn slightly to the left on crying. Eyes. — Apertures are equal. Sclerse and conjunctivae are clear. External ocular movements are good, no paralysis of orbicularis. Pupils are equal, not dilated, react slightly to light. Ears. — No tenderness or discharge. Nose. — No dis- charge, nares patent. Month. — Lips and mucous membranes are of fair color. Tongue has a heavy coat, muscles are intact. Pharynx is injected. Tonsils are not enlarged, and there is no exudate. Neck. — No retraction. There is slight resistance to flexion. On sitting up the head falls back and to the right. There is paralysis of the anterior neck muscles and sternocleidomastoids. Superficial lymph nodes. — The glands on both sides of the neck are palpable and shotty. Chest.— Well formed and symmetrical. There is slight flaring of the costal border. Breathing is diaphragmatic in type. Ribs do not move. There is retrac- tion of the bony wall on inspiration. There is slight action of the accessory muscles of respiration. The diaphragm descends, and seems fairly strong. Respiration is slightly rapid, short, and jerky. Lungs.— Clear on ausculation and percussion. Heart.— iiorrml. Abdomen.— The abdomen moves well with respira- tion. Walls are relaxed. There is no bulging in the flanks, no masses or local tenderness. Superficial abdominal reflexes are absent. Extremities.— Upper: the right arm has very slight power of flexion of the fingers, otherwise it is in a Digitized by Microsoft® 150 A Clinical Study of Acute Poliomyelitis. state of complete flaccid paralysis. The deltoid and posterior arm muscles are paralyzed on the left. Other movements are possible but weak. Lower : the right thigh can be extended with a strong tendency to outward rotation. The toes and foot can be extended. On the left side there is slight power of outward rotation with slight extension of the thigh. Otherwise flaccid paralysis is complete on both sides. There is pain on full flexion of the leg but no Kernig's sign. Knee jerks, Achilles reflexes, and Babinski test are all absent. Tempera- ture. — 99.6° F. September 22. Spinal fluid : 20 c.c. of perfectly clear fluid, pressure slightly increased; cells, S per c.mm. ; mononuclears, +-+"> globulin, o; sugar, +. Blood count: leukocytes, 17,100; differential count of 200 cells: polymorphonuclears, 38 per cent.; lymphocytes, 49 per cent.; large mononuclears, 1.5 per cent.; transi- tionals, 11 per cent.; basophiles, o; eosinophiles, o; stimulation form, 0.5 per cent. September 25. The alse nasi are working this morning a little more than before. The child shakes his head from side to side frequently. Evidently this is the only way of attempting to escape from the discomfort of breathing and general sense of helplessness. September 26. Spinal fluid: 30 c.c. of clear limpid fluid, pressure very slightly increased; cells, 15 per c.mm.; globulin, ±; sugar, .+. September 27. Spinal fluid : 10 c.c. of clear watery colorless fluid, pressure not increased ; cells, 4 per c.mm. ; all mononuclears ; sugar, + ; globulin, slightly +. September 28. The patient continues to breathe only with the diaphragm. There is no return of power in the lower extremities or arms. The child sleeps little at night but dozes from time to time during the day. October 3. Blood count: leukocytes, 17,200; differential count of 200 cells: polymorphonuclears, 49.5 per cent. ; lymphocytes, 39 per cent. ; large mono- nuclears, 6.S per cent.; transitionals, 3.5 per cent.; basophiles, o; eosinophiles, I per cent.; stimulation form, 0.5 per cent. October 4. The patient has improved markedly in the past three or four days. He whines less and looks stronger and brighter. He breathes strongly with the diaphragm. Spinal fluid : 14 c.c. of clear fluid, pressure not increased ; cells, 2 per c.mm. ; globulin, + ; sugar, +. October 18. During the past week the patient has seemed somewhat brighter. There is, however, no change in his paralysis. The neck is apparently unable to hold up the head. There is no return of costal respiration. October 20. Spinal fluid : clear, colorless, and watery ; cells, 2 per c.mm. ; mononuclears, + ; globulin, slightly + ; sugar, +. Noveinber 2. The child really makes no progress. He is a miserable, sick child. The neck muscles are still so weak that the head drops backward when he is sitting up. The back is very weak. The power of the right arm is completely gone except for flexion of the fingers. The left upper arm is paralyzed. Breathing is practically wholly diaphragmatic. The intercostals are paralyzed. The child still has pain on moving the legs. He does not look so bright or so well as he did two weeks ago. The chest is clear except for a few rales in the * back. November 3. Spinal fluid : clear, colorless ; cells, 3 per c.mm. ; mononuclears, + ; sugar, +; globulin, very slightly +. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 151 November 17. Yesterday morning there was a beginning broncliitis on both sides. In the evening both lungs, front and back, were full of coarse, moist rales. No rise in temperature was noted. Respiration was rapid and wholly abdominal. Complete paralysis of the intercostals persists. The chest has seemed to become smaller and more shrunken, an appearance probably due in part to atrophy of the pectorals and intercostals, associated with the soft pro- tuberant belly. This morning the child looks better. His temperature is 100° F., and the rales are not quite so numerous. November 19. The condition remains the same. Both sides of the chest are full of coarse moist rales. The heart action is good. There is no especial rise of temperature. November 21. The temperature is still normal. The rales have cleared up remarkably, and the chest is almost clear. The child looks much better. November 26. The patient continues to do well. This morning there are a few, low pitched, coarse rales in both sides of the chest near the bases. The breathing is still entirely diaphragmatic. The abdomen is greatly distended. The patient has gained in weight and looks very fat and well. The neck is not yet able to support the head, and the back is very weak. The child goes home today. CASE 17. Edward G., age, 3 years and 8 months. New York City. Admitted, August 12, 1911. Discharged, August 23, 1911. Result, well. Diagnosis. — Acute pohomyelitis. Family History. — Negative. Past History. — T^e patient has always been healthy. Present Illness. — Last Sunday, August 6, six days ago, the patient came to his mother and said he did not feel well and wanted to lie down. He was sleepy and complained of headache. On Monday he walked about a little, but went to bed again and has been there since. He has had no appetite, has not been irritable, and has had no tenderness. On Tuesday he either could not or would not speak, and has not spoken since. He has eaten nothing since Tuesday. He had not vomited until yesterday, when he vomited a little after taking medicine. He did not lie quietly, but threw himself about in bed. At times he has seemed almost to have convulsions. Bowels have not been regular. He has passed urine normally, but has not voided since yesterday. Urination induced by appli- cation of hot compresses. No sore throat. The mother noticed no weakness of the arms or legs, but says there is some stiffness in the neck. Physical Examination. — The patient is a well developed, rather thin, very sick looking child. He lies quietly on his back, eyes half closed, and pays no atten- tion to his surroundings. He cannot be roused by questions and is very dull. The skin is dry, quit* warm, and clear, except for a few old scabs on the legs and arms (bites). The face is symmetrical. Eyes. — The eye slits are equal. Eyes apparently move normally, but it is impossible to rouse him enough to make him follow an object with his eyes. Pupils are equal, and react normally. Ears.— No discharge or tenderness. Nose. — No discharge or excoriation. Mouth. — The lips are covered with dry crusts, no herpes. Teeth are dry and in fair condition. Tongue has a thick grey coat. The tonsils are only a little enlarged. Tonsils, pillars, and pharynx are reddened; no exudate. The pharynx is full of grey Digitized by Microsoft® 152 A Clinical Study of Acute Poliomyelitis. mucopurulent material. Neck.— There is very slight resistance to flexion, no retraction. Superficial lymph nodes.— There are firm discrete enlarged glands in the neck, axillae, and groins. C/i^j*.— Somewhat chicken-breasted, no definite rachitic rosary or Harrison's groove. Chest is symmetrical and moves normally with respiration. Heart.— iiegative. Lungs.— Clear on percussion and ausculta- tion. ^&dom^».— Level, soft, tympanitic, no masses or tenderness, symmetrical, moves normally with respiration. Abdominal reflexes are present. Bladder is distended. Liver.— Flatness extends from the sixth space to the costal margin. Edge is easily felt. Spleen.— 'Not felt. Muscular system.— Legs : reflexes, all normal. No paralysis or weakness of leg muscles. Arms: both move equally and strongly. Back and abdominal muscles are strong. Neck muscles: the child can sit up straight, but after a short time his head falls backwards. He has very little power to straighten his head up again, and usually lets it con- tinue to hang backwards. Temperature. — 99-8° F. August 12. Blood count: leukocytes, i5,40o; differential count of 200 cells: polymorphonuclears, 63 per cent. ; lymphocytes, 17 per cent. ; large mononuclears, 5 per cent.; transitionals, 8.5 per cent.; basophiles, o; eosinophiles, 6 per cent.; stimulation form, 0.5 per cent. Spinal fluid: 30 c.c. of perfectly clear watery fluid, not opalescent; pressure, 330 mm.; cell count, 31 per c.mm. ; globulin, slightly cloudy, within normal limits; sugar, -{- after heating; sodium chloride, 0.70 per cent.; smear, small mono- nuclears, 96 per cent. ; large mononuclears, 4 per cent. August 14. The child is much brighter, is wide awake, and will sit up alone. He does not respond well to questions and still prefers to be let alone. The neck muscles are much stronger. Movement of the head is painful but he can hold his head up well. The right knee jerk is very slight and is obtained with difficulty. August 15. Urination has been normal since admission. August 18. Spinal fluid : 20 c.c. of clear colorless fluid ; no blood ; pressure slightly increased (crying) ; cell count, 7 per c.mm., all mononuclears; globulin, very slight opalescence, normal ; sugar, -|-. August 23. Spinal fluid: 15 c.c. of perfectly colorless watery fluid; cell count, 6 per c.mm., all mononuclears; globulin, very slightly +, turbid; no flocculi; sugar, -|-. Eyes, ears, and throat are negative. There is no stiffness of the neck. Neck, back, and abdominal muscles are strong. Movements of the legs and arms are normal. The child walks well. He blinks a good deal, and seems to have some photophobia. The patient is discharged well. CASE 18. Mary H., age, 8 years. New York City. Admitted, October 2, 1911. Dis- charged, October 22, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Past History. — The patient has always been a healthy child. Present Illness. — Last Thursday, September 28, four days ago, the patient vomited. She had been perfectly well on Wednesday night. The doctor gave her some medicine and she stayed in bed all that day and was drowsy. She did not sweat much. Slept fairly well Thursday night. On Friday she seemed much better and asked for food, but stayed in bed. That night she was restless. Satur- Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 153 day morning her father saw her suddenly become stiff, but she did not have a convulsion. This passed rapidly, and during the day she became more and more stuporous. The doctor said that it was either typhoid or meningitis. The child was restless during the night. Yesterday morning (Sunday), and throughout the day, she was in a very stuporous condition. Yesterday evening Dr. Huber was called and made a diagnosis of infantile paralysis. About 9:00 p. m. yester- day evening, the patient could swallow only very weakly. One eye could not be closed. She was restless during the night; no sweating. She has been con- stipated. Physical Examination. — The patient is a well nourished little girl, tall and slender. She lies on her back with head to the right. The right eye is closed, the left open. She is in a stuporous condition from which she can be roused by handling or by sharp questions and orders. She will perform any simple act, such as putting out the tongue, raising the eyebrows, etc. She does not become irritated during the course of the examination, but accepts it all passively. She is very apathetic. There is incontinence of urine. Face. — The left half of the face is completely paralyzed. The eyebrows cannot be moved, the eye cannot be shut, and when she shows her teeth the right side pulls far over. Eyes. — Pupils are equal, react rather sluggishly. The left eye slit is wide and cannot be closed. The ocular motions are a little incoordinate, there being a definite weak- ness of the right internal rectus so that an internal strabismus of the right eye is present most of the time. Ears. — Normal. Nose. — Normal. Mouth. — The tongue is heavily coated. There is much thick, grayish, sticky mucous in the back of the mouth. The buccal mucous membrane is red. The pharynx is very much congested ; tonsils not present. Neck. — The neck is stiff to flexion. Anterior muscles are weak. She cannot keep the head from falling backward. Swallow- ing is weak. Superficial lymph nodes. — The posterior cervical are somewhat en- larged. Axillary and inguinal nodes are just palpable. Chest. — Rather long and narrow, moves only very slightly in respiration, but if the patient takes a deep breath it moves normally. Lungs. — Clear. Heart.' — Normal. Abdomen. — Soft, flat, no tenderness, no masses. Enlargement of liver and spleen is not evident. Extremities. — Upper: no weaknesses. Lower: no weaknesses. Knee jerks are very active; Achilles reflexes active. On testing for the Babinski sign, there is slight rapid initial flexion and then marked extension of the great toe. Oppen- heim reflex is present. Kernig manipulation is resisted actively near the end and the child complains of pain. Temperature. — 99.6° F. October 2. Spinal fluid: 14 c.c. of clear fluid, pressure not increased; cells, 20 per c.mm. ; mononuclears, + + ; globulin, very slightly -f ; sugar, -|-. Blood count: leukocytes, 12,000; differential count of 200 cells: polymorphonuclears, 75 per cent. ; lymphocytes, 13 per cent. ; large mononuclears, 3.5 per cent. ; transi- tionals, 8 per cent.; basophiles, o; eosinophiles, i per cent.; stimulation form, 0.5 per cent. ' This evening the patient was fed by gavage. She has difficulty in managing fluid in the mouth and pharynx and has much distress from thick saliva. October 3. The patient is still very dull, but can be roused and responds slowly to questions. Some weakness of the right deltoid seems to be present this morning. The brachial reflex on the left is present, on the right absent. October 4. The child is markedly brighter this morning. Both eyes are open Digitized by Microsoft® 154 A Clinical Study of Acute Poliomyelitis. and she is no longer stuporous. She is still apathetic. There is slight internal strabismus of the right eye. There is no improvement of the left facial paralysis. The patient can speak coherently this morning, and says she has a little pain in her left foot. The knee jerks are present, but not especially active; they are about normal. The left Achilles reflex is much more active than the right. She has no loss of power in arms or legs, though she complains of pain in the left foot. The anterior neck muscles are weak, for the patient's head drops back when the trunk is lifted forward by the shoulders. In the sitting position she can hold her head up. October 8. The child is much improved. She swallows easily and takes food well. Facial paralysis remains very marked. The right knee jerk is not obtained, the left is present. Both Achilles reflexes are present. Movements of both legs are normal. CASE 19. Fred S., age, S years. Orange, N. J. Admitted, July 14, 191 1. Discharged, July 30, 191 1. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — One sister, 15 months old, admitted to this hospital at the same time as the boy, was paralyzed five days before him. Habitat : family lives in a separate house with a large yard. They have lived there for nine months. Last August, one year ago, there were two cases of paralysis, one an infant and one seventeen years old, occurring in different houses just across the street. Past History. — Negative. Present Illness. — The child vomited on July 19, the day the baby became sick. He was well for five days and then was taken sick with a high fever, 102° F., and complained of pain in his head. The next day the right side of the face was drawn up. There was no ptosis. The eye movements have been good. No trouble with swallowing. Can talk normally. Three days after the onset the left arm was limp for about twenty-four hours. Then the fever left and the condition has remained stationary. There has been no nasal discharge and no eruption. After the first twenty-four hours he seemed to have no pain. The bowels have been constipated during the illness. Appetite is good, no vomiting. Physical Examination. — The patient is a bright active child who responds readily to questions. The head is well formed and held in normal position. Eyes. — External ocular movements are good, no ptosis. The left palpebral fis- sure is wider than the right. Pupils are equal and react to light and accommo- dation actively. The sclerae and conjunctivae are clear. Ears. — No tenderness over the mastoids, no discharge. Hearing is acute. Foce.— The right side is contracted and the left side lax and drooping. The mouth is drawn down par- tially to the right when in repose and moves well upward to the right on smiling. Both sides of the forehead can be wrinkled, but the wrinkles on the right go higher than on the left. On frowning, contraction is equal on both sides. He uses both eyes well. Masseters strong on b9th sides. Mouth.— Th^ tongue can be protruded in the mid-line. Lips and mucous membrane are of good color. Teeth are good. The tongue has a slight white coat. Tonsils, quite large on the right, easily visible on the left. They are not injected, their muscles move well. ATecA.— Muscles are strong, no rigidity or tenderness. Superficial lymph nodes. —The right cervical, both axillary, and both inguinal glands are easily palpable, but not especially enlarged. Thorax.— WeW formed ; costal angle ninety degrees. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 155 The chest moves easily with respiration. No rachitic rosary. Expansion good and equal. The thorax is everywhere resonant on percussion and clear on auscul- tation. H^orf. ^Negative. Abdomen. — Soft throughout ; no tenderness or i-igidity ; moves with respiration. The muscles are strong. There are no masses. Liver. —Dullness extends from the fourth interspace to the costal margin in the right mammary line. Edge is not felt. Spleen.— The^ edge of the spleen is just felt on deep inspiration. Extremities. — No weakness of the arms. Grip a trifle stronger on the right than on the left. Brachial reflexes are active on both sides. Movements and strength of the legs are unimpaired. Patellar reflexes very active on both sides. Achilles reflex obtained on both sides. Plantar responses normal. Sensorium. — No hyperesthesia or muscular tenderness. Temperature. — 99° F. July i6. Blood count: leukocytes, 13,400; differential count of 200 cells: polymorphonuclears, 58.5 per cent. ; small mononuclears, 25.5 per cent. ; large mononuclears, 14.5 per cent. ; eosinophiles, 0.5 per cent. ; transitionals, i per cent. ; red cells, normal in size and shape ; no nucleated forms seen. General condition is good. The arms and legs move perfectly well. The abdominal muscles are normal. There is paralysis of muscles of expression on the left side of the face (seventh nerve) ; the masseter is normal. The tongue protrudes slightly to the right. The folds of the face are obliterated on the left, the right side of the mouth is drawn up. The right eye is partially closed by drawing up of cheek. Pupillary and eye reactions are normal. Hearing is apparently good and equal on both sides. July 29. The tongue protrudes to the right but it can be put out to the left. Face: the right side of the mouth is drawn upwards, especially when he laughs. The asymmetry is not marked when face is at rest. The forehead wrinkles on both sides but most on the right. Arms : movements of both are strong and normal. Legs move strongly and normally. Knee jerks and Achilles reflexes are active on both sides. Residual paralysis of the left side of the face (seventh nerve). Patient is discharged. October 7. The child returned for observation. He is in good condition but the mother reports that he is very nervous and timid. He is afraid to go any- where alone. His face is a little better, but still shows some asymmetry on smiling. CASE 20. Jerry E. S., age, 3 years and 10 months. Lakewood, N. J. Admitted, October 8, 1911. Discharged, November 14, 1911. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat : the family lives in a single house, clean and airy. They have no animals. The family have been at Jefferson, N. H., for three months, and the children have all been well. Three families lived in the house there, but there was no sickness in the house. The house was clean, there were no parasites, and no pet animals except one dog. They know of no cases of infantile paralysis in Lakewood or Jefferson. Past History. — Negative except for a birth palsy of the left arm. Present Illness. — On October 4, four days ago, the child said that he did not feel well. " He laid around " and would not play or eat. The next day he felt worse and lay on the couch all day and seemed inclined to sleep. That afternoon Digitized by Microsoft® 156 A Clinical Study of Acute Poliomyelitis. his speech was less plain. The next day, Friday, he was kept in bed all day; speech was about the same, he could talk, but not distinctly. He seemed rather dull and restless, but there was no evidence of pain until yesterday, when he kicked and cried and seemed to be in pain. Two days ago his mother noticed that he could not swallow, and his mouth seemed to fill with phlegm. He has not eaten or drunk anything for three days. He has tried to swallow milk and water but it comes back. He vomited at the onset and on the second day. Bowels have moved with enema, urination has been normal. Face has seemed sym- metrical. The child has had no convulsions. He had a cough and raised some phlegm, but has difficulty in getting rid of it. He has not sweat at all and has had no chill, but has been feverish for the last three nights. There has been no evidence of paralysis of arms or legs. His speech has been worse than it is today. Physical Examination. — The patient is a well nourished small boy. He lies on his side with head slightly retracted and knees drawn up. He objects to being turned on his back, and struggles actively to regain the lateral position. His face is flushed and he hes in a soporific condition from which he is easily aroused by any manipulation which tends to place him on his back. Eyes. — The left pupil is a trifle wider than the right ; both react normally. Ocular motions are normal. There is no strabismus. Ears. — Normal. Nose. — Normal. Mouth. — Tongue is heavily coated, and the mouth is filled with thick grey mucous, which collects in the pharynx and which the patient cannot get rid of. He evidently cannot swal- low or change the position of the fluids in his mouth. Pharynx is reddened, tonsils are somewhat enlarged. Neck. — The neck is a little stiff to flexion. Muscles are weak and head lolls back when the trunk is raised forward. Super- ficial lymph nodes. — The posterior cervical, axillary, and inguinal nodes are palpable but not enlarged. Thorax. — Well formed. Moves properly in respira- tion. Lungs.— CitSLV. Heart.— ViormsX. Abdomen. — Soft, not distended, no masses or tenderness. Liver and spleen not felt. Extremities. — Upper are normal and strong. Lower are strong and active. Knee jerks on both sides are, perhaps, slightly increased. Temperature.— 101.4,° F. October 8. Spinal fluid : pressure not increased ; cells, 18 per c.mm. ; globulin, very slightly hazy; sugar, + (?). Blood count: leukocytes, 19,300; differential count of 200 cells : polymorphonuclears, 73 per cent. ; lymphocytes, 18.6 per cent. ; large mononuclears, 2.6 per cent; transitionals, 4.6 per cent.; basophiles, 0; eosinophiles, o; stimulation form, 0.6 per cent. October 10. The child is somewhat brighter. There is no return of swallow- ing. He is receiving nasal feedings of milk and eggs, and salt solution by rectum. He usually regurgitates after the feedings and sometimes becomes quite blue. He has great difficulty in expelling the regurgitated food and the mucus from his mouth. When told to stick his tongue out he says, " I can't." When he tries he hardly gets it beyond his teeth, and it protrudes quite markedly to the right. No other paralysis is found. October 12. Tongue paralysis is very definite, chiefly on the right side. Swallowing shows no improvement. The child is fed by nasal catheter. Speech has improved considerably since admission, but is still far from distinct. In gen- eral the child is somewhat brighter. Spinal fluid: a few c.c. of clear watery fluid; no increase of pressure; cells, 90 per c.mm. ; globulin, very slightly + ; sugar, -i-. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. R. Dochez. 157 October 14. The tongue protrudes definitely to the right. It is still impos- sible for him to swallow. Speech is not at all clear. The face is symmetrical. The pupils are equal. The neck resists flexion, which is painful. Movement of both legs is painful especially the right. He keeps the right leg flexed at the knee, and, when, any one handles it, resists any attempt to straighten the leg, this being very painful. Pressure over the calf and below the patient's leg is painful. The right knee jerk is not obtained (when the leg is held fairly flexed). Knee jerks and Achilles reflexes gre active on the left. The movements are less painful. October 20. The child is still being fed by stomach tube. He is not, how- ever, losing much weight. For the last few days he has been getting more quiet, and takes very little interest in his surroundings, but he rouses when his mother comes. Yesterday his voice became much more weak and hoarse. He said his throat hurt him. A laryngoscopic examination was made but the vocal cords could not be seen. Today he breathes quietly, but has said very little and speaks in a very faint voice. His tongue deviates to the right. There are no other paralyses. The reflexes are normal. Later in the day. Spinal fluid : clear, colorless ; cells, 3 per c.mm. ; mono- nuclears, -{-•, sugar, -f-; globulin, slightly -j-. October 21. Yesterday the patient caused surprise by swallowing a few cubic centimeters of water. Later in the evening he swallowed 20 c.c. of milk. This morning he took 150 c.c. of egg nog without difficulty. October 30. The child swallows very well now, solid food better than liquids; in fact liquids still cause some trouble, but they have been swallowed much better in the last few days. His voice has been very weak and is still hoarse and weak but much better. He has complained greatly of pain, when being dressed or moved; but much of this seems to be fear, for today when his attention was diverted his legs were moved, and he moved them well himself and sat up straight without pillows and had no pain. October 31. Spinal fluid: 5 c.c. of clear watery fluid; pressure not increased; cells, 3 per c.mm. ; mononuclears, -\- ; globulin, very slightly hazy (normal limits) ; sugar, -|-. November 4. The patient walks better, but still with a swaying, shaky, almost ataxic gait. His legs are spread so that his feet are wide apart, and the right foot is usually held in outward rotation. The legs are moved and held rather stiffly. Both knee jerks are exaggerated, and both Achilles tendons give almost clonic response. There is a suggestion of ankle clonus but not a true clonus. The psychic condition is very interesting. The child is normally a rather quiet, silent, stubborn child. He is now distinctly nervously " on edge " and is ready at any moment to laugh or cry. Usually he ends by crying and without any particular reason. At times when some one is playing with him, he only answers by a series of nervous grunts, something between a giggle and a sob. November 13. The child is in good general condition. He is still somewhat nervous and cries rather easily, but is quite different from what he was a fort- night ago. The child swallows all foods normally. His voice is loud but some- what husky. The tongue still protrudes toward the right, and there is slight atrophy of the right side of the tongue. Both legs move actively and normally. Knee jerks and Achilles reflexes are exaggerated on the right, much exaggerated Digitized by Microsoft® 158 A Clinical Study of Acute Poliomyelitis. on the left. Babinski and Kernig's signs are negative. There is a suggestion of ankle clonus on the left. The gait is much improved. He walks well and can run but still spreads his feet rather widely. His gait is perfectly steady, how- ever. There is slight Romberg's sign. The child is discharged today. CASE 21. Helen N., age, 6 years. New York City. Admitted, September 17, 191 1. Discharged, October 9, 1911. Result, improved. Diagnosis. — Acute polio- myelitis. Family History.— Negative. The family lives on West S7th Street. There are ten families in the house, one other on the floor on which the patient lives. The house is old and fairly clean and airy. There are many waterbugs and bedbugs, but very few flies and mosquitoes. There are, however, many fleas as the family has a pet dog and pups. There are no sick children in the neighborhood. Past History. — The patient has always been a healthy child. Present Illness. — Last Sunday, September 10, seven days ago, the patient was perfectly well and happy. On Monday evening she complained of nausea and vomited a little. From that time on she began to be dull, drowsy, and slept most of the time. She complained of headache and tired feeling. Wednesday even- ing she was a little irrational. A doctor was called, who said that the child had diphtheria and gave her antitoxin on Thursday morning. On Friday she did not recognize the family and had a vacant stare. There were no convulsions, but twitchings of the hands, feet, and eyelids. Another doctor saw her Friday and said she had meningitis. Temperature was then 105° F. On Saturday the patient was in a rather deep coma. Bowels have been constipated but moved yesterday with enema. The child has not spoken for the last two days. Physical Examination. — The patient is a fairly nourished little girl who lies on her back, still, and apparently semicomatose. Occasionally the eyes roll under the half closed lids. She can be roused by handling. When the feet and hands are prodded, the legs or arms are drawn away sharply. She breathes regularly and by the normal mechanism, though perhaps a trifle less deeply than is normal. The face is rather flushed and has a slightly bluish tinge. Eyes. — The pupils are narrow, the right just a little smaller than the left. The eyes do not move quite coordinately. The conjunctivae are injected, and there is a purulent secretion in the left eye. Eye grounds are apparently normal. The disc is sharply defined. The veins look a little full. Nose.— No excoriations or discharge. . Mouth.— The teeth are in poor condition, some of the front ones broken. The buccal mucous membrane is reddened. The tongue is heavily coated. The pharynx is very red, the tonsils large. There is a thick mucopurulent mass in the pharynx with some yellowish white membrane-like shreds. Superficial lymph nodes. — Posterior cervical, axillary, and inguinal nodes are palpable. A^eck. — Not rigid. Thora.v.— Moves properly, though slightly in respiration. Lungs.— ClesiT. Heart.— Action is regular, not rapid, sounds not very loud. Abdomen.— Normal Extremities.— Upper : apparently normal. Lower : power is apparently good. Both knee jerks are absent, both Achilles reflexes active. Babinski and Kernig's signs are absent on both sides. There is slight reaction to pain at the end of Kernig manipulation. Surface. — Clear. Temperature. — 101° F. September 17. Blood count: leukocytes, 23,200; differential count of 200 Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 159 cells : polymorphonuclears, 76 per cent. ; lymphocytes, 17 per cent. ; large mono- nuclears, 3 per cent.; transitionals, 2.5 per cent.; eosinopliiles, i per cent.; basophiles, o; stimulation form, 0.5 per cent. Spinal fluid: 25 c.c. of clear fluid; pressure 14 cm.; cells, 37 per c.mm. ; mononuclears much increased; globulin, slight haziness, well within normal limits; sugar, +. September 18. The child lies on her back in a drowsy condition. There are no rose spots and the spleen is not felt. There is no muscle stiffness of the neck, and no Kernig's sign. p. M. There is slight but distinct weakness of the muscles closing the right eye. September 19. This morning the patient is a great deal brighter. She looks at things about her a little more intelligently and she will slowly follow with her eyes an object that is moved in front of her face. She will answer simple questions. The ocular motions seem to be coordinate but slow. The pupils are equal and react sharply to light. The right palpebral fissure is a little wider than the left, and the patient is unable to close the eye. There is also very slight flattening of the right side of the face. No weakness of arms or legs is found. The knee jerks are still absent. The temperature which was 102.2° F. on the day of admission has been falling steadily for the past 36 hours and is now 99.2° F. The pulse rate has followed a parallel course. The von Pirquet reaction is negative. The neck is perhaps a trifle stiffer than yesterday. The patient com- plains of pain when her shoulders are lifted forward. p. M. The patient is found wide eyed and crying. When questioned she says that she is better and wants to go home. Her mind is almost entirely clear, but she is a little slow in responding. The right knee jerk was obtained once or twice after repeated attempts, but not the left. No further paralysis is noted beyond that of the muscles supplied by the seventh nerve. Spinal fluid: 22 c.c. of perfectly, clear fluid; pressure slightly increased; cells, 44 per c.mm. ; mononuclears much increased ; globulin, very slightly -}- ; sugar, -|-. September 20. This morning the patient is still brighter. She lies quietly, however, preferably with knees drawn up, and does not like to be handled much. There is definite tenderness over the muscles on either side of the spine between the shoulders. There is no weakness in the arms or legs. The knee jerks are not obtained. Right facial paralysis is marked this morning. It is complete in the upper half with only weakness of the lower. The patient was taken from bed and put on the floor. She was a little unsteady in balance, but could stand and also walk. September 21. Spinal fluid: 5 c.c. of clear Hmpid fluid; pressure not in- creased ; cell count, 57 per c.mm. ; globulin, very slight haziness ; sugar, +. September 25. This morning the child is bright and happy. During the last few days she has been inclined to be irritable. The paralysis of the right seventh nerve is receding a little. She cannot close the right eye. The knee jerks have returned on both sides. Achilles reflexes are as before. The child sits easily and also stands. September 27. The patient is better. The knee jerks are both active. Paral- ysis of the upper half of the distribution of the seventh nerve is still marked. Spinal fluid: 25 c.c. of clear limpid fluid; pressure slightly increased; cells, 11 per c.mm. ; globulin, very slight haziness ; sugar, -|-. Digitized by Microsoft® 160 A Clinical Study of Acute Poliomyelitis. October 9. No change in facial paralysis. The knee jerks are very markedly exaggerated, especially the right, which responds with almost a clonus. The Achilles jerks, too, are much exaggerated. There is no weakness in the extremities. The patient walks well and her general condition is good. CASE 22. Johanna W., age, 3^/4 months. New York City. Admitted, October 13, 191 1. Died, October 15, 1911. Diagnosis.— Acute poliomyelitis. Family History.— This, baby slept in the same bed with her sister, Margaret, who was taken sick on October 4 and became paralyzed on October 5. Margaret used to let the baby suck the nipple of her nursing bottle. Pa.fi History.— The child is a nursing baby and has always been very strong. Present Illness.— On Wednesday, October 11, two days ago, the mother noticed that the baby looked sick and feverish. The next day she was taken to a doctor who said that the child had a fever of 102° F., but did not pronounce it infantile paralysis. She has not vomited until today when she vomited in the examining room, nor has she sweat much. She has had no convulsions and has not seemed to have much pain. The main symptom has been sleepiness. Bowels moved with medicine; movements green. Physical Examination. — The patient is a well nourished infant who seems drowsy. When handled she tries to cry, but cannot make any noise. She looks like a very sick baby. Eyes. — Pupils are equal. There is possibly a slight con- vergent strabismus. Nose. — The alae nasi move slightly in respiration. Mouth. — The tongue is slightly coated with a whitish fur. Pharynx is reddened, tonsils somewhat large. H^arf.— Anterior fontanelle bulges a very little (diminished after lumbar puncture). ATec^.— Patient cannot hold her head up. The posterior muscles are not stiff to flexion. Superficial lymph nodes. — ^The posterior cervical and occipital nodes are palpable. Thorax. — Well formed. It does not move properly in respiration. The whole thoracic cavity is drawn down with each inspiration. There is apparently complete intercostal paralysis. Lungs. — Clear. Heart. — Apparently normal. Abdomen. — Full, not distended. The urinary bladder reaches nearly to the umbilicus. Patient does not void. Abdominal respiration is marked. Liver and spleen are not felt. Extremities. — October 13. There is complete flaccid paralysis of both lower extremities this afternoon. Knee jerks and Achilles reflexes are absent on both sides. There is no Kernig's sign present and Kernig manipulation does not cause pain. There is apparently flaccid paralysis also of the right deltoid and upper arm. The left has tone. October 14. The left arm also seems to be flaccid this morning. Surface. — A few fine petechia are scattered over the surface. Spinal fluid: 30 c.c. of very slightly opalescent fluid, pressure not increased; cells, 423; globulin, slightly +; sugar, +. Blood count : leukocytes, 25,300 ; differential count of 200 cells : polymorpho- nuclears, S9 per cent.; transitionals, 13.5 per cent.; lymphocytes, 23.5 per cent.; basophiles, 0.5 per cent.; large mononuclears, 2.5 per cent.; eosinophiles, 0; stimulation form, i per cent. The child is drooling at the mouth. Her face and lips are cyanotic. The respirations are short and shallow and the lungs clear. There is practically no movement of the ribs on the left side, although there may be slight retraction Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 161 on inspiration; on the right side the ribs move slightly. Abdomen moves with respiration but the diaphragm seems weak. At intervals there is a deep forced inspiration. The accessory muscles of respiration are called into play. Respiration is irregular this afternoon, and at times is of a Cheyne-Stokes character, two or three deep forcible inspirations and then a pause in which one hears a few very shallow and weak respirations; then again two or three deep breaths. The strong expirations are associated with a forcible jerky upward movement of the diaphragm. Pressure on the abdomen and blocking of the action of the diaphragm causes great distress and difficulty with respiration. The child is very limp; there is apparently paralysis of the legs, intercostals, arms, and neck. She is very pale and slightly cyanotic. The accessory muscles of respiration (sternomastoids) are used, and occasionally the child throws her head back and her lower jaw forward with inspiration. October 15. The child gradually grew weaker during the night and, without change in symptoms, died at 6:30 a. m. CASE 23. Helen K, age, 3 years and 10 months. Bergenfield, N. J. Admitted, August 19, 1911. Died, August 21, 1911. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat: the family lives alone in a house in the country. The next house is twenty-five feet away. The house is new and clean. They have one pet dog which is healthy. No parasites. No possible con- tact of child or parents with anyone lame. The family has lived in the country for iive years. Past History. — The child was normal at birth, had chicken pox as a baby and measles last year. No scarlet fever or diphtheria. She has always had a weak stomach and vomits occasionally. Present Illness. — Last Wednesday, August 16, three days ago, the child went to Rockaway. The day before she was perfectly well. She ate very little breakfast that morning before starting for the seashore, vomited while on the cars, but on arrival ate a big dinner. In the afternoon she went wading in the surf and had a chocolate soda. Then she began to feel sick and complained of a headache. She ate no supper. At 8 p. m. she vomited, and vomited three times that night. She was restless at night and very feverish. No especial tender- ness, but rather irritable. The next morning she vomited again. The doctor thought she had "wind on the stomach." At this time she walked but was " weak on her legs.'' There was no change all day. Yesterday she was about the same. Her legs were weak, she could walk, but did not want to stand. She sat up last evening and fed herself at supper. The mother says her arms and legs " quivered " yesterday. At three o'clock this morning the mother put her on the water closet and she " collapsed." The mother then noticed that she could not move her arms. She has had a fair appetite, has vomited frequently, and the bowels have been constipated. No convulsions, no especial sweating. She has been very dull and sleepy for several days. Her mother thinks she passed no urine yesterday. She complained of headache at first and pain in the back,, but not in the arms and legs. Two days ago her voice became very weak. It is more normal now. Physical Examination.— Th^ patient is a well built, apparently strong child. Digitized by Microsoft® 162 A Clinical Study of Acute Poliomyelitis. Sensorium is clear, but she is distinctly dull and sleepy. The cheeks are some- what flushed, lips and conjunctivx of good color. The face is symmetrical. Eyes.- — Pupils are equal, regular and react normally. Ocular movements are normal. No strabismus. Ears. — No discharge or tenderness. Nose. — No dis- charge or excoriation. Mouth. — The tongue protrudes straight and has a thick gray coat. Lips are dry, no herpes. The teeth are in fair condition. Both tonsils are large but not reddened, and there is no exudate. Neck. — The neck resists flexion and attempt to flex is painful. Chest. — Well formed and symmetrical. Costal angle just under ninety degrees. Respiration is almost wholly abdominal ; chest moves very slightly with respiration. When the hand is put over the abdomen and pressure made to obstruct the diaphragm, there is no increase in thoracic respiration, and she complains that she cannot breathe and respiration gets more rapid. There is no marked rosary or Harrison's groove. Lungs. — Inspiration is short, clear throughout on auscultation and percussion. Heart. — No enlargement. Left border inside nipple line. Action is regular and rapid. Sounds are of good quality. A soft systolic murmur is heard over the pre- cordium. Abdomen. — Level, soft, symmetrical, tympanitic, no masses or tender- ness. Abdominal reflexes not obtained. No tache cerebrale. Liver. — Flatness extends from the sixth rib to the costal margin, edge not felt. Spleen. — Not felt. Muscular system. — Legs : movements of both legs are possible, no paralysis can be made out. There is possibly some weakness, but the child is so sick that it is hard to be certain of this. The Achilles reflex is present on both sides. The other reflexes are negative. The left quadriceps acts well. The attempt to elicit Kernig's sign causes pain and muscular spasm which prevents complete exten- sion. Arms : the shoulder muscles are completely paralyzed. The child can flex and extend the forearms at the elbows but does so very weakly. Flexion and extension of the fingers and extension of the hands dorsally are possible, but all movements are weak. The child can sit up, but the neck muscles are weak and the head has a tendency to drop backwards or sideways. The back muscles seem strong. She sits up well. Sensation: there is pain in the back of the neck on flexion and on attempting Kernig's sign. No especial hyperesthesia noted. The voice is somewhat rasping and harsh, but strong. August 19. Blood count: leukocytes, 10,000; differential count of 200 cells: polymorphonuclears, 61 per cent. ; large mononuclears, 6.5 per cent. ; transitionals, S per cent; lymphocytes, 26.S per cent.; eosinophiles, 0.5 per cent; stimulation form, 0.5 per cent. Spinal fluid: 20 c.c. of absolutely clear, colorless, watery fluid; pressure, 180 mm.; cell count, 120 per c.mm. ; sugar, +; globulin, very slight turbidity, normal; smear, practically all the cells are mononuclears and nearly all are lymphocytes. August 20. The temperature is still elevated. The weakness of the hands seems more marked. Legs : there is definite weakness of the quadriceps on both sides. Knee jerks are both absent. Other movements are pretty strong. The Achilles reflex is not obtained on the right, and is slight on the left The respiration is 42 to the minute; it is wholly abdominal and is very jerky. On pressure over the abdomen and upwards towards the diaphragm, respiration becomes more rapid and labored, and her face becomes quite flushed. No move- ment of the chest surely referable to intercostals was discovered. The child complains of pain in the back, but of no other tenderness. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 163 August 21. Urine examination: yellow, turbid; reaction acid; Fehling's test for sugar negative ; test for albumin with heat and acetic acid negative, with potas- sium ferrocyanide negative. No change in the child's condition yesterday. She was restless during the night but respiration remained the same until it suddenly changed at 7 o'clock this morning and the doctor was sent for. The child is lying on her back. The sensorium seems perfectly clear. The skin has a pale grayish color. The lips are dark red, rather cyanotic. The child is in a profuse sweat. The pupils are equal, regular, and react normally. Ocular movements are normal. The tongue protrudes straight. The temperature is normal. The child has difficulty in swallowing but takes some milk. She raises frothy mucus which she does not spit out, but holds between her lips and waits for it to be wiped off. Her respiration is short, jerky, and wholly abdominal. The upper part of the chest moves with respiration but is pulled down on inspiration. The abdominal respiration is normal. With inspiration the alje nasi dilate, and there is a pro- trusion of the lower jaw. The sternomastoids and muscles of the neck stand out. Lungs: the right front is clear, respiration normal; left front, the respiration is very feeble; both backs are full of coarse moist rales. The heart is regular and normal. The abdomen is negative. The legs are as before, perhaps weaker. The arms are as before, movements of the hands weaker. The general condition is quite characteristic. She is perfectly clear mentally and speaks clearly but rather abruptly, telling exactly what she wants, " My arm hurts," " Turn me over," " Scratch my nostril." Apart from this, she desires to be let absolutely alone. " Don't touch my chest," " Leave me alone, doctor," she says. Her bowels have moved twice ; after each movement the child is somewhat more cyanotic. 10 A. M. The child is very cyanotic, her respiration is irregular and jerky. She is moribund. The pulse is regular at 64; then it suddenly becomes more rapid, perhaps 100 (still regular) for a series of beats, then gradually drops down to about 64 again. Respiration becomes more feeble and sviddenly ceases. The heart continues to beat forcibly and regularly for some minutes. Then it becomes more feeble and somewhat irregular, though in general the arrhythmia is of the type with a series of beats at regular rhythm, changing to a series of regular beats at another rate. The heart beats become more infrequent, and the heart stops beating five and a half minutes after respiration stopped. CASE 24. Alfred K., age, 15 months. New York City. Admitted, October 14, 191 1. Died, October 17, 191 1. Diagnosis.^Acute poliomyelitis. Family History. — Negative. Habitat: the family lives in bad surroundings. The house is an old wooden structure with a bakery in front and living rooms in the rear. The bedrooms are dark. There are flies, mosquitoes, and all varieties of vermin. There have been no acute infections in the house lately. There have been no cases of poliomyelitis in the immediate neighborhood, but there was one case two blocks away " some time ago." Past History.— The patient has always been a healthy child with the exception of some slight gastro-intestinal trouble. Present Illness. — The onset was rather sudden on Monday night, October g, five days ago. The child was restless, could not sleep, cried a great deal, and seemed to have pain in the head. There was no spontaneous vomiting, but the child was Digitized by Microsoft® 164 A Clinical Study of Acute Poliomyelitis. given ipecac and then vomited a little frothy mucus. On the next day he had a fever. Three days ago he had a slight convulsion, and on the following night had short general convulsions involving the whole body with the exception of the lower extremities. He has had muscular twitchings and a coarse tremor of the hands. There has been no nasal discharge. Sphincters have not been affected. Two days ago paralysis of both legs was noticed and at that time all reflexes were absent. Yesterday there was beginning weakness of the right arm. There has been no respiratory involvement. Temperature, pulse, and respiration have been as follows : October lo, temperature 102.6° F., pulse 140, respiration 60. October 11, temperature 102.6° F., respiration 48. October 12, temperature 101° R, pulse 130, respiration 36. October 13, temperature 100.2° F., pulse 120. October 14, temperature 98.6° F. Child has been very constipated, urination has been normal. Physical Examination.— The child is a well developed, strong baby, lying quietly on his back. The eyes are open and the child is not asleep, but he seems languid and takes no interest in anything. The head is square and the cranium bulging. Anterior fontanelle is not closed. The face is symmetrical. Eyes.— Pupils are equal, regular, and react normally. Ocular movements are normal. . Eyelids close normally. Eo«.— No discharge or tenderness. Nose.—iJo dis- charge or excoriation. Mouth.— Th-e tongue has a thick gray coat. There is a distinct groove in the median line. The lips are dry. Both tonsils are enlarged and boggy; no exudate and no especial redness. Superficiallymph nodes. — There are small glands in the neck, axilla, and groins. Neck. — The child resists flexion, it evidently causes pain. Chest. — Well formed, costal angle ninety degrees, moves normally with respiration, no rosary or Harrison's groove. Lungs. — Qear throughout. Heart. — Normal in size, sounds clear. Abdomen. — Full, very soft, tympanitic, no masses or tenderness. Abdominal reflexes are barely obtained. There is no tache cerebrale. The abdominal muscles lack tone and seem very weak. There is no contraction when the child sits up. Liver. — Flatness extends from the sixth rib to the costal margin. Edge is just felt Spleen. — Not felt. Muscular system. — Movements of the arms seem strong. Legs: both knee jerks, both Achilles reflexes, and both Kernig's signs are absent. There is no resistance to the Kernig manipulation on the right, and on the left only slight tightening of the external hamstring as the leg is extended (muscles all paralyzed), but extension is quite painful. There is no tenderness on pressure over the legs. Back: when the child is made to sit up the body falls forward over the legs, bending at the hips. There is paralysis of the gluteals, erector spinae, and neck muscles. The head cannot be held up but drops loosely forward, backward, or to one side. Cremasteric reflexes are active. Surface. — The skin is rather dry but not hot. There is no rash. The lips are slightly pale. October 17. Spinal fluid : 6 c.c. of clear, colorless, watery fluid, pressure low ; cell count, 114 per c.mm. ; mononuclears much increased; globulin, very slightly + ; sugar, +. The child does not look so well. He appears weaker and his respiration is rapid. The temperature has not risen. The' child has some difficulty in swallow- ing, but can still take food. The tongnie is apparently straight, but he will not stick it out. The chest moves well with respiration. The accessory muscles take some part in respiration. The abdomen moves paradoxically. There is distinct Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 165 retraction on inspiration, paralysis or weakness of the diaphragm associated with the weakness of the abdominal muscles noted before. On auscultation both sides of the chest are full of coarse moist rales, the fronts more so than the backs; there is no consolidation. The legs are paralyzed. The arms and face are unaffected. The child does not cry at all loudly (laryngeal involvement?). II :30 A. M. The child has changed remarkably in the last hour. He is quite cyanotic and the respiration is short and labored. Breathing has become worse and the heart irregular (Luciani periods) until respiration practically stopped. Artificial respiration was then begun and camphorated ether injected. In a few minutes the heart was regular and rapid, and respiration fairly regular and deeper than before. His color was much better, and child could breathe alone. The intercostal muscles appear to be weakening now. With each respiration the lower ribs flare, but there is little or no movement of the upper ribs. The diaphragm is not descending. There is increasing activity of the accessory muscles of respiration in the neck. They are acting strongly, and with each inspiration there is a depression and protrusion of the lower jaw. The irreg- ularity of the heart seems to bear some relation to cyanosis, increasing as the color gets worse. The child is unconscious. The skin has been gray and cyanotic since this attack began. It is quite edematous and marks of the stetho- scope over the chest and also over the shins persist for a long time. During the , period of apnea which occurred suddenly and in which the child appeared to be dying, the heart action assumed a curious irregularity, but one which was similar to that which we have seen in several other cases of respiratory failure. The heart would beat regularly at a rate of about 84 for a period of 10 seconds and then at a rate of 36 for 6 or 7 beats. This alternation of rapid and slow series of beats occurred over a considerable period of time, probably a minute and a half or two minutes. During the latter part of this time, artificial respiration was being carried on, and the heart action then became regular and rather rapid. When the patient began again to breathe spontaneously, the heart rate became rather slower and continued to be regular. After about 10 or 15 minutes the child again had respiratory failure. This time, however, the heart did not show the rhythmical changes in rate, but gradually became slower and weaker with slight sinus arrhythmia from time to time. The heart continued to beat, giving the normal sounds, at a fairly regular rhythm for three minutes after the breathing finally stopped, at least nothing could be heard after three minutes, except possibly the vaguest sound in the region of the second right interspace. Electrocardiographic records, however, show that an action current was formed for 24 minutes after breathing stopped and 21 minutes after the sounds had' become inaudible. CASE 25. Jesse L., age, 5% years. New York City. Admitted, July 20, 191 1. Died, July 20, 1911. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat: the family lives in a fifteen family house and knows of no sickness in the same house. The child and the parents do not remember ever having come in contact with anyone who is lame or paralyzed. The child has been in New York since last summer when he went for a few days to the country. There are no animals in the house. The building is old, but fairly clean and airy. Digitized by Microsoft® 166 A Clinical Study of Acute Poliomyelitis. Past History— Tht child has always been perfectly well. Present Illness.— On Wednesday, July 12, eight days ago, the mother noticed that the child was feverish. She gave him citrate of magnesia, and the next morn- ing he appeared to be well. On the following three days, Thursday, Friday, and Saturday, the child was up and played normally. Saturday night, however, five days ago, the child complained of pain in the back and was very restless and tired. He slept poorly and the next morning complained of severe pain in the head and back. He was given castor oil and vomited. Dr. Taylor saw the child in the evening. At this time he had pain and a stiff neck and his temperature was 102° F. Note by Dr. F. L. Taylor, who has had the case under his care since July 16: "The child has been ill for three days— apparently some digestive disturbance and coryza. Was given castor oil by mother. Last night complained of intense frontal and occipital headache; pain in the back of the neck and upper dorsal spine with retraction of head. Tendon reflexes were perhaps slightly exaggerated. There was twitching of the individual muscles of the extremities as the patient lay in bed. Temperature 102.2° F. (rectal) ; pulse 150. Has Kernig's sign and no Babinski reflex. Respiration 50 to 60 and shallow. Heart, lungs, and abdomen negative. Leukocyte count, 7,000; polynuclears, 81 per cent. Monday morning, July 17, condition unchanged. Lumbar puncture: 15 c.c. of crystal clear cerebrospinal fluid obtained under some pressure (i. e. came out in a spurt) . Dififerential count shows polynuclears, 71 per cent. ; lymphocytes, 21 + per cent. ; endothelial cells, 2 + per cent. ; incubation negative. Tuesday : reflexes obtained; tendency to somnolence; takes nourishment well. Temperature, pulse, and respiration about the same. Wednesday afternoon : respiration 36, tempera- ture 101° F., pulse 120, quite somnolent, very weak. Urine: specific gravity 1,009, slightly acid, clear, heavy deposit of phosphates, no albumin, no sugar. Cell count : leukocytes, 3,000 ; polynuclears, 58 per cent. ; small lymphocytes, 28 per cent. ; mononuclears, 14 per cent. During the night the child had great difficulty in breathing, partial paralysis of the muscles of respiration, left arm, and left leg." The mother says that she first noticed weakness of the legs on July 18, two days ago. There has been no vomiting other than at the onset except yesterday when the child vomited once ; no undue sweating. The mind has been clear. Physical Examination. — The patient is a well built little boy, lying on his back. He is perfectly conscious and aware of all that goes on around him, but talks with difficulty in a very weak voice. Respiration is very labored and rapid, the alae nasi dilating with inspiration, and with each inspiration there is a marked contraction of the sternomastoids on both sides. Associated with this is an extension of the neck and a protrusion of the jaw. The chest itself does not move at all with respiration. The abdomen moves in a normal manner, but the excursion of the abdominal wall is limited and weak. The skin is clear and white. Mucous membranes are pale. There is no discharge from the nose. The lips are covered with dry crusts. Eyes. — Movements of the eyeballs and pupillary reactions are normal. Ears. — Hearing is apparently normal. There is no dis- charge and no tenderness over the mastoids. Mouth. — The tongue is coated and protrudes straight. The teeth are in good condition. The tonsils are enlarged and ragged; there is no exudate. No herpes. Superficial lymph nodes. — There are small glands in the neck, axillae, and groins. Chest. — Well formed, costal Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 167 angle about ninety degrees. The chest does not move with respiration. Heart.— Normal. There is a systolic murmur all over the precordium, most marked at the pulmonary area. Lungs. — Both fronts are normal on auscultation and per- cussion, but the breath sounds are very feeble. As far as can be ascertained, the backs are also normal, but turning the child over disturbs him greatly. Abdomen.— Level, soft, tympanitic, no masses or tenderness. Abdominal wall moves normally with respiration, but to a limited extent. The abdomen is symmetrical. Liver. — Flatness extends from the sixth rib to the costal margin. The edge is not felt. Spleen. — Not felt. Muscular system. — Legs : the Achilles reflex is present on the right side, the other reflexes are negative. Movements of the legs : it is difficult to ascertain how far the legs are paralyzed and how far lack of movement is due to weakness alone. His mother says that he can move the right leg, but no movements were seen. The left leg is very weak and flaccid, apparently completely paralyzed. Arms : the hands, wrists, and forearms can be moved on both sides. The muscles of the shoulders are apparently paralyzed, for the child seems unable to move his upper arms. Face : the face is not quite symmetrical. There is slight smoothing out of the right side of the face. The folds on the left side are somewhat more marked than on the right. This becomes more definite when the child talks or smiles. July 20. 3 :30 P. M. The pulse is irregular. At the apex a series of beats is heard at a rate of about 100 ; then the rate suddenly changes to 120 to 140, and a series of regular beats occurs at this rate. The rhythm of both rates is regular. Each rate may continue for three to four beats or perhaps twenty or more beats, then there is a quick change to either a slower or faster rate. The fast rate is not so much as twice that of the slow rate. No abortive beats and no compensatory pauses are heard. Between the most rapid rate and the slowest, other variations in rate seem to occur. The arrhythmia reminds one of rapidly recurring attacks of paroxysmal tachycardia. Later. After admission the child's condition became gradually worse. He could at first speak a few words, though articulation was difficult. His lips moved and one could see that he was trying to talk, and after a few attempts he managed to utter a few words, such as " a drink of water " ; the words were clear and distinct. After the first few hours he became unconscious. Movements of the limbs were few, presumably from weakness. Respiration was very labored and seemed to involve a voluntary muscular effort. The chest wall did not move. There was paralysis of the intercostal muscles. The muscles coming into play most actively were the sternomastoids and the platysma on both sides. The scaleni appeared not to act. On admission, the diaphragm was acting normally, but weakly. The diaphragm became weaker and weaker, i. e., the movement of the abdominal wall became less and less, and towards the end it was scarcely noticeable. As death approached, respiration continued to be very rapid, 40 to 50, was even more short and gasping than before, and seemed to be carried on almost wholly by the sternomastoids and other neck muscles. The heart meanwhile continued to act strongly, showing constantly the type of arrhythmia noted above, an irregular hurrying and then slowing, simulating more a rapidly recur- rent paroxysmal tachycardia, than an auricular fibrillation with pulse intervals of constantly varying lengths. The strong action of the heart up to the end was in marked contrast to the constantly failing respiration. The child took no Digitized by Microsoft® 168 A Clinical Study of Acute Poliomyelitis. nourishment, only sips of water. Whether or not he could swallow could not be determined. He refused even on admission to take more than just enough fluid at one time to moisten his lips, which were very parched. Respiration grew weaker, the child became unconscious and at 7 p. m. died, of respiratory failure. The child was extremely pale on admission. Cyanosis was not especially marked until the very end, and even then it was no more marked than one usually sees it just at death. It was at no time a prominent sign. CASE 26. Roger P., age, 4 years. Hawthorne, N. Y. Admitted, September 20, 1911. Died, September 23, 1911. Diagnosis.— Acute poliomyelitis. Family History.— The father and mother are living and well. There are two other boys in the family, aged two and nine years. Both have been per- fectly well. All three children had measles last May. The two year old boy was slightly indisposed seven days ago. He was somewhat irritable and had little appetite but no vomiting or diarrhea. The family Hve in a small village in a house with grounds. The air and light are excellent. There are few mosquitoes, no roaches or other bugs, but large numbers of flies. The children have played about with other children in the neighborhood. T. R., who now has poliomyelitis in the Hospital, lives in the same village, but the patient had not been in the habit of playing with him. There are no other cases in the neighborhood. Past History. — The patient has always been a strong healthy child. Present Illness.— On Saturday, September 16, four days ago, the child suddenly complained of pain in the right leg. On trying to run about, the leg seemed somewhat weak. At that time he also had slight fever and very little appetite. He was kept in bed most of the time but on Monday afternoon, was up and able to walk about a little without assistance. He has not walked since, however. It has been noticed that his left arm has been very weak and also his back. The voice has seemed somewhat thin. He has not vomited and has had no convul- sions. He has been rather drowsy, complained " of headache and pain in the stomach, and has been constipated since Saturday. No retraction or rigidity of the neck has been noticed. On the evening of September 18, and yesterday morn- ing, respiration was rapid and shallow, but it did not appear to be so last night He has not urinated since this morning. Physical Examination.— The child lies quietly on his back. He seems drowsy and does not respond readily to questions. The expression is rather dull. There is no evident distress. Color is good, skin hot and moist. Head. — The head is well formed; no frontal bosses. Face. — The right side of the face is slightly relaxed, and the mouth is drawn to the left on smiling. Eyes. — Pupils are equal, not dilated, react actively to light. There is no ptosis. External ocular move- ments are good. Sclerae and conjunctivae are clear. Ears. — No discharge or tenderness. Mouth. — Lips and mucous membranes are of good color. The tongue has a moderately moist white coat. Pharynx is not injected. Tonsils are not large; no exudate. Neck.— The head falls back on sitting up, so that there is evidently paralysis of all the anterior muscles. There is no retraction, the child resists bending forward because of pain. Superficial lymph raorfej.— Not en- larged. Chest. — Well formed and symmetrical. Expiration is almost impercep- tible. Breathing is purely diaphragmatic. The lower ribs do not move on Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. \m inspiration. The upper portion of the thorax is pulled up slightly on inspira- tion, although there is no marked action of the accessory muscles. The dia- phragm descends well but seems a little weak. There is no pulling in of the ribs at the attachment. Respiration is shallow with an occasional, deep, sighing inspiration. Lungs are clear on percussion and auscultation. Abdomen. — The abdomen moves normally with respiration. The muscles seem soft and relaxed. There is no bulging in the flanks, no masses or tenderness. Superficial reflexes are absent on both sides. Extremities. — Upper : the grip of both hands is weak. There is no wrist drop. The fingers can be extended and flexed. Movements of the forearm are good. There is paralysis of the deltoid on both sides. Reflexes are absent. Lower: there is complete flaccid paralysis of the left leg. The toes of the right foot can be slightly flexed. Right leg : there is paralysis of the quad- riceps, iliopsoas, and extensors of the foot, and weakness of the posterior muscles of the right lower leg. The toes can be fairly well flexed. The right gluteus and the hamstrings are active. All reflexes are absent on both sides. An attempt to elicit the Kernig's sign causes pain, but no muscle spasm. September 20. Blood count: leukocytes, 12,400; differential count of 200 cells : polymorphonuclears, 53 per cent. ; transitionals, 12 per cent. ; lymphocytes,. 24 per cent; basophiles, o; large mononuclears, 9.5 per cent; eosinophiles, o; stimulation form, 1.5 per cent. Spinal fluid: 22 c.c. of clear fluid; pressure slightly increased; cells, SS per c.mm. ; almost all mononuclears; globulin, very slightly -|-; sugar, -)-. Later, near midnight, the patient could be seen just beginning to use the accessory muscles in the neck, and the alae nasi were also working. September 21. The child slept fairly well. This morning the costal muscles seem entirely paralyzed, and the accessory muscles in the neck are working much more obviously. The diaphragm is acting but not strongly. The lungs are clear. There is localized sweating of the upper lip. Later in the morning: the respira- tory embarrassment is much more marked. The right side of the abdomen moves more than the left with inspiration, as though the left side of the diaphragm were not working. The child is drowsy but is easily aroused, and then is a little irritable. He can move the forearms and hands but not the shoulders. The pupils are equal and contracted. In the afternoon the diaphragm seems to gain strength and the abdomen moves evenly and with a somewhat greater excursion. The rate of respiration is rather low, considering the amount of respiratory embarrassment. The breath sounds are not heard below .the junction of the lower and middle third of the axilla. There are no rales. Towards evening the heart rate increased and a sinus arrhythmia was noted. There was some difficulty in swallowing noted, but this seemed at first due as much to increase of respiratory embarrassment as to actual failure of the muscles of swallowing. Later, however, quite definite failure of deglutition was noted. The child throws his head from side to side at times and cries weakly, seemingly trying to escape from some oppression. He cannot articulate clearly. The eyes are bright, but often he dozes, and the eyeballs roll up beneath the incompletely closed lids. September 22. The patient slept fairly well. This morning he is breathing with about the same degree of embarrassment as yesterday evening, perhaps a trifle more easily. The rate of inspiration varied between 22 and 30 during the- Digitized by Microsoft® 170 A Clinical Study of Acute Poliomyelitis. night. The temperature is falling by a fairly steep curve. The patient's color is good. He seems to be getting enough air. This morning he is .rather more drowsy than he has been. He cannot articulate properly, but he swallows much better than yesterday evening. Occasionally he moves his head vigorously from side to side. The arms are moved more extensively than yesterday. The abdomen moves about as much in respiration as yesterday, perhaps the right side a little more than the left. p. M. The patient has gone on well through the day. He breathes a trifle more easily this evening. The abdomen certainly makes a slightly greater excur- sion on inspiration than it did this morning. The child takes his fluids much better this evening. This morning he had much difficulty in swallowing. He is more willing to try to speak and succeeded in articulating and phonating the words " good-night " weakly but distinctly. September 23. This morning about 5 :30 the patient began to weaken markedly. His color is not so good; there is a faint tinge of cyanosis on the lips and duskiness about the eyes. He is pale. The breathing is much shallower than last night. The heart action is fairly strong. From time to time there is definite sinus arrhythmia. The child's mind is quite clear and he can speak. He knows perfectly well what he wants and does not want. The left side of the diaphragm evidently does not descend at all, for that side of the abdominal wall remains motionless. From time to time faint, blotchy, localized flushings appear on the face and fade again. At 10:35 a. m. the first heart sound has become rather tapping and sharp in quality. The action is somewhat slower and also more constantly irregular, though the arrhythmia is very slight. p. M. The patient has been breathing less and less deeply through the day. Cyanosis of the finger tips has been gradually developing and a slightly more dusky appearance of the face and lips. The left side of the diaphragm is apparently not acting at all. The abdomen is becoming distinctly more scaphoid, and the tissues are losing their elasticity. The child is in a rather deep coma, from which he can be roused, however, by persistent prodding. He swallows with difficulty. About two hours before death the child suddenly seemed to come out of his coma for a. few moments and looked about him with perfectly clear eyes and apparently recognized his parents. This transient return to consciousness was of extremely short duration, and he rapidly lapsed again into coma. Follow- ing immediately upon this, the child's breathing became suddenly worse and in a few moments stopped entirely. He looked as though he had died. During the period of respiratory pause which lasted, with the exception of one or two shallow gasps, for nearly two minutes, the heart continued to beat, at first regularly as before, but after a few seconds with a noticeable irregularity. This soon took the form of alternating series of regular rapid beats and regular slow beats. The sounds conveyed the impression that tracings from the heart taken at the time would have shown a typical curve of Luciani periods. At the end of the long respiratory pause, the patient suddenly began to gasp more deeply and in a few breaths had resumed his previous respiratory rhythm. This con- tinued for nearly two hours longer and then stopped suddenly as it had in the first instance. Electrocardiographic records were taken at short intervals throughout the last eight or nine hours of life. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 171 CASE 27. George G., age, 9^ years. Brooklyn, N. Y. Admitted, August 30, 191 1. Died, September i, 1911. Diagnosis. — Acute poliomyelitis. Family //u^ory.— Negative. Habitat: the family lives in a double house, which is quite new and is clean and airy. No parasites are found in the house. There is no history of any contact of parents or child with any lame or paralyzed person. Past History. — The child has always been healthy. Present Illness. — The present illness began about a week ago. The child felt poorly, was given physic, and soon appeared perfectly well again. No definite symptoms were noted until Sunday, August 27, three days ago, when he com- plained of stiff neck. He vomited once the same day after a meal, but has not vomited since. He has had no convulsions, and the mother has noticed no pro- fuse sweating. At the onset he had headache and indefinite pain in both thighs, lasting a few hours, but besides this has had no especial pain. Throughout the illness his mind has always been clear. He eats well, but his bowels are con- stipated. He has no trouble with voiding, no cough, or sore throat. He has been kept in bed, and his illness was considered to have been cerebrospinal meningitis. There was no history of paralysis until this morning (11:00 a. m.) when he had lost knee jerks, and the muscles of his legs were flaccid and motion- less. Since then the left arm has become involved (noted at 4:00 p. m.). This morning his respiration was entirely abdominal and his thorax was motionless. Ejcpiratory grunt was also noted. He has not been drowsy and not especially restless. Physical Examination. — The patient is a rather slim, well built boy. He lies on his back with his eyes open and is evidently quite alert, noticing all that goes on. He responds to questions brightly but with a very weak voice. Respiration is rapid, rather jerky, and labored. The alse nasi dilate with respiration and the muscles of the neck, especially the sternomastoids, take an active part in respira- tion. The chest itself is quite motionless. Respiration is wholly of the abdominal type, but the impression is given that the diaphragm is not acting very strongly. There is slight protrusion of the lower jaw with inspiration. The face is sym- metrical. The skin is rather dark in color ; no rash. Eyes. — The pupils are equal, regular, and react rapidly to light. Ocular movements are normal. Eye slits are equal. Ears. — No discharge or tenderness. Nose. — No discharge or excoria- tion. Mouth. — The tongue protrudes straight and has a thick gray coat. The tonsils are not enlarged. The pharynx is negative. The child can swallow milk well. Neck. — There is stiffness of the neck and resistance to flexion, but no retraction. Superficial lymph nodes. — The glands in the neck, axillae, and groins are just palpabje. Chest. — Well formed and symmetrical. Lungs. — Clear throughout on ausculation and percussion. Heart. — Not enlarged, action regular and rapid. Sounds are of good quality. A soft systolic murmur is heard all over the precordium, most marked in the pulmonary area. Abdomen. — Slightly dis- tended, soft, tympanitic. No masses or tenderness. Abdominal reflexes and cremasteric reflexes are not obtained. Muscular system. — Legs: knee jerk and Achilles reflex are absent on both sides. Babinski reflex is negative on both sides and also Kernig's manipulation, which is slightly painful. Movements : no movements are obtained in either leg except flexion of the toes. Sensation : the Digitized by Microsoft® 172 A Clinical Study of Acute Poliomyelitis. touch of a camel's hair brush is easily felt over both feet and lower legs. Arms : there is apparently a paralysis of both upper arms. The child can flex and extend the fingers weakly and can flex both elbows. Abdominal muscles : there seems to be some tone to the abdominal muscles. The neck and back muscles were not tested. The boy is so sick that an accurate localization of the paralysis is impossible. August 30. Blood count: leukocytes, 16,700; differential count of 200 cells: polymorphonuclears, 75 per cent. ; lymphocytes, 15 per cent. ; large mononuclears, o.S per cent. ; transitionals, 9.5 per cent. August 31. The boy's condition is about the same. He is bright and alert and appears to be making a good fight. Each breath he takes comes with obvious effort. Except for breathing, however, he makes no effort to move. When he speaks it is in a low voice, and he only speaks in order to answer questions or to make known his requests. He says respiration is easier than last night. He asks to have his nightgown loose about his neck, to be turned over, etc. Physical examination shows nothing new. No rales in the lungs. The respiration is abdominal, and the movement of the abdomen seems weaker than last night. The upper part of the chest moves with respiration, but this movement seems to be due to the pull of the neck muscles. The arms seem a little weaker. Afternoon. The excursion of the abdomen in respiration is very slight. Later in the evening there seemed to be 'a distinct improvement in the patient's condition. He answered questions more fully, moved his head more, and in gen- eral did not display the extreme economy of muscular effort seen earlier in the day. The breathing was distinctly less shallow. Abdominal excursion was fair. Urine examination: clear, amber; specific gravity 1,017; reaction acid; Fehling's sugar test negative; albumen test with heat and acetic acid negative; sediment, heavy, yellow, granular precipitate. September i. The patient dozed for short periods during the night. At 6 o'clock, breathing became worse. The patient was cyanosed, especially about the lips. The effort to expand the chest was great, and spent chiefly through the sterno- cleidomastoids, the muscles of the floor of the mouth, and the hyoids. The pull on the inner end of the clavicles was such that a partial anterosuperior disloca- tion of the sternoclavicular articulation resulted with each inspiration. Slight protrusion of the epigastric region indicated weak diaphragmatic action. This continued practically to the end. About one half to three quarters of an hour before death the heart action, which had been regular and moderately strong, began to show irregularity. At first this seemed to be an occasional sinus arrhythmia. A little later, however, alternating stretches of slower regular, and more rapid regular rates were observed. Sometimes the rapid period was entered by a gradually and evenly increasing rate. The slow rate was usually approached more abruptly by a few, irregular, slower beats. There was no change in the quality of the sounds. Notwithstanding the respiratory difficulty and the failing heart, the lungs remained clear of adventitious sounds until a few minutes before death, when some scattered rales appeared in the lower left axilla. The patient remained semi-conscious almost until the last, although a somewhaf delirious muttering was present for two hours or more before death. There was a slight inequality of the pupils, the left being a little larger, during the last hour or more. The heart continued to beat very weakly and regularly for a minute or two after respiration ceased. The sounds could be heard over the base but not at the apex. Digitized by Microsoft® Francis W. Peahody, George Draper, and A. B. Dochez. 173 CASE 28. Belle T., 8 months old. New York City. Admitted, August 21, 1911. Died, August 23, 1911. Diagnosis.— Acute poliomyelitis. Family History. — The mother and father are living and well. There is one other child in the family, who subsequently also developed poliomyelitis and died. Past History. — The child is one of twins. She has always been healthy except for erysipelas at the age of three months. Present Illness. — On Friday, August 18, the mother noticed that the child was feverish. The doctor was called on Saturday morning. At this time, the child had a temperature of 103° F., pulse 120, and was very nervous. The throat was red and inflamed, and there was a slight patch on the right tonsil. In the even- ing the throat was clearer, but the temperature remained at 103° F., the breath- ing became more rapid, and a few rales were heard. The doctor said it looked like pneumonia. Later in the evening the temperature fell to 101° F., pulse no. August 20, the child appeared brighter and not so nervous, but she was not so lively as usual. She slept well that night. Next morning, she was again seen by a physician who noticed twitching of the face and a peculiar movement of the toes of the left foot, almost rhythmical in character. About this time weakness was also noted in the left arm and leg. At noon the same day, August 21, Dr. Francis Huber made a diagnosis of poliomyelitis. During her illness there has been no vomiting and the bowels have been normal. Physical Examination. — The patient is a well nourished infant who lies quietly and is rather somnolent. She frets a little if handled much, but lapses rapidly into the sleepy condition. The expression is a drowsy one, and not alert. Eyes. — There is a slight but definite internal strabismus. The pupils are equal and react normally to light and accommodation. Ears. — Normal. Mouth. — The buccal mucous membrane is clean. The pharynx is a trifle reddened. The tonsils are a little enlarged. Head. — The anterior fontanelle is open widely; no bulging or pulsation. Neck. — Not stiff. No power in the neck muscles is apparent; the head drops when the baby is sitting up. Superficial lymph nodes. — The cervical nodes are palpable. Thorax. — Well formed, moves very little in respiration. Lungs. — ^Apparently normal. Heart. — Apparently normal. Abdomen. — Rather prominent, moves properly and rather widely in respiration. It is soft, there are no masses, but palpation of the abdomen seems to produce discomfort. Ex- tremities. — Upper right: no definite weakness is found. Left: there is definite loss of power in the shoulder muscles, probably in the biceps also. Flexors and extensors of the hand, and extensor of the forearm are weakened but not para- lyzed. Lower right : there seems to be complete weakness of the thigh muscles. The flexors and extensors of the foot are still intact. Left : practically the same condition exists on the left though not quite so marked. The reflexes are absent on both sides. August 21. This evening a few fine dry rales are heard along the inner border of the left scapula. Respirations are very rapid and short, but the diaphragm is working well. Blood count: leukocytes, 23,900; differential count of 200 cells: polymorphonuclears, 25 per cent. ; large mononuclears, 2 per cent. ; lymphocytes, 57 per cent. ; transitionals, 25 per cent. ; eosinophiles, i per cent. August 22. Urine examination: pale yellow, clear; reaction acid; Fehling's test for fupar negative; test for albumen with potassium ferrocyanide negative; slight pediment. Digitized by Microsoft® 174 A Clinical Study of Acute Poliomyelitis. August 23. Last evening the breathing, which had been extremely rapid since admission, was not so deep, and the alae nasi were moving. They had not been active previously, even with the high respiratory rate. This morning the respiratory motions are much more short and jerky. The floor of the mouth and glottis are drawn down forcibly with each inspiration. There is considerable power in the dorsal flexors of the left foot. The right is much weaker. The knee jerks are both absent, likewise Achilles reflexes. The child is drowsy and apathetic. The heart action is regular and strong, 174 per minute. There are a few rather moist rales on the left lung. The abdomen seems to move more on the left side than on the right, and the viscera appear to move downward and toward the right with each contraction of the diaphragm, as though the left half of the muscle were acting more strongly than the right. It is almost impos- sible to determine whether the abdominal muscles are paralyzed. There seems to be a very faint reflex on the left, none on the right. During the morning the child's condition gradually becomes worse. From time to time beads of perspira- tion appear on the lips and forehead. The accessory muscles of respiration arc brought more and more actively into play. There is a striking collapse of all the tissues. The rotundity of outline has gone almost visibly from the costal margins, the abdomen becoming more and more scaphoid and the tissues looking faded and inelastic. The motion of the left side of the abdomen is very marked, the right side is practically motionless. From time to time the tongue is pro- truded, and the lips are opened and shut as though to moisten the mouth. Frothy saliva covers the tongue and lips. There is cyanosis of the tongue, but the lips are marked rather by pallor than by blueness. The whole face is pale. Heart rate, 192 to the minute at I :20 p. M., action strong and regular. The rales are still present over the left anterior axillary region. The breath sounds are somewhat better heard over the lower left chest than the lower right. The pupils are equal and remain strongly contracted. They react, however, to light. During the afternoon the respiration becomes constantly weaker. The left half of the diaphragm continues to act but the respirations are very shallow and jerky. The child dies suddenly at about 5 p. m. CASE 29. Frances K., age, 21 months. Perth Amboy, N. J. Admitted, September 11, 1911. Died, September 16, 191 1. Diagnosis.— Acute poliomyelitis; broncho- pneumonia. Family History. — Negative. Past History.— The child has always been healthy except for an attack of bronchitis last year. Present Illness.— On Wednesday, September 6, the patient was perfectly well. On Thursday she had a slight fever, was restless, and evidently had pain when handled. The restlessness continued on Friday with loss of appetite and alter- nating constipation and diarrhea. On Saturday the doctor noticed paralysis of the rig-ht arm and slight weakness of the neck. There was an increase of paralysis of the neck on Sunday and the child vomited once. Today there is possibly some weakness of the left arm also. The child has had no convulsions. No urinary symptoms. Physical Examination.— The patient is a well nourished little girl, who lies Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Bochez: 175 quietly without moving and is very pale. She dozes easily, but can be aroused and made a little fretful by handling. She is breathing very fast. Eyes.— The. pupils are equal and react to light. The left eye has a slight external strabismus. Ocular motions are coordinate. Nose. — No secretions, no excoriation. Ears.— Normal. Mouth. — The tongue is heavily coated, grayish yellow. The pharynx is reddened; the tonsils are much enlarged. ATecfe.— There is flaccid paralysis of the anterior and most of the posterior muscles. Attempt at flexion causes pain. Superficial lymph nodes. — The posterior cervical, axillary, and inguinal nodes are enlarged. 77iora.i:.— Well formed ; respiration almost entirely thoracic. Lungs. — Clear. Heart. — Rapid, regular. Abdomen. — Retracted in inspiration; soft. Liver and spleen not enlarged. Extremities. — Upper: there is flaccid paralysis of the entire right arm, and of the left shoulder and arm. There is some power in the forearm (flexors). Wrist drop is present. Lower: the reflexes are absent on both sides. Kernig manipulation is painful, but resistance to it is voluntary. The left quadriceps is weak. Temperature. — ioi° F. September ii. Spinal fluid: 20 c.c. clear limpid fluid; pressure not increased; cells, 174 per c.mm. ; globulin, o ; sugar, + ; polymorphonuclears, 3 per cent. ; mononuclears, 97 per cent. Blood count : leukocytes, 26,300 ; differential count of 200 cells : polymorphonuclears, 70 per cent. ; lymphocytes, 16.5 per cent. ; large mononuclears, 3 per cent. ; transitionals, 9 per cent. ; basophiles, 0.5 per cent. ; eosinophiles, 0.5 per cent. ; stimulation form, i per cent. September 12. This morning the temperature is 103° F. The child is breath- ing rapidly and almost entirely with the thorax. The alae nasi are working more than they were last night. There is no advance of paralysis. The child is very ill. September 13. The temperature at 8:00 a. m. is 100.8° F. Breathing is rapid and slightly irregular, purely costal in type. The accessory muscles of respiration are not brought into play. The ribs move well, the costal border flaring well out. Condition of paralysis unchanged. September 14. The patient is not so well this morning. There is a faint tinge of cyanosis on the lips and a duskiness over the forehead. The alse nasi are working strongly. Accessory respiratory muscles in the neck are beginning to work. The thorax still expands well, but the impression is given that the musculature is becoming fatigued. The patient has rather a fixed distant expres- sion in the eyes, and occasionally the lids droop and the eyeballs roll slowly upward, sideways, and back again. The temperature continues between 101° and 102° F. The pulse rose to 160 this morning. It is small and very weak. Throughout both sides of the chest there are numerous scattered moist and sibilant rales. Transient vasomotor phenomena are seen in the irregular flushings of the face. Spinal fluid: 15 c.c. of clear fluid; pressure not increased; cells, 44 per c.mm.; largely mononuclears ; globulin, o ; sugar, -f-. September 15. This morning the patient seems perhaps a little brighter than yesterday. The costal breathing is as strong as ever. The cyanosis is distinctly less. The alae nasi are working as before. There is slightly more marked impairment of resonance over the left upper chest anteriorly and in the left axilla than on the right. The adventitious sounds consist chiefly of loud squeaks and coarse sounds. Posteriorly the rales predominate and are of a distinctly moist character. There are also many scattered rales over the right lateral and Digitized by Microsoft® 176 A Clinical Study of Acute Poliomyelitis. posterior aspects of the chest. There is a slight expiratory grunt. The tempera- ture continues between ioi° and 102° F. The pulse rate is high and is stronger this morning. 8 .30 p. M. Numerous rales can be heard, and over the lower axilla there is a distinct bronchial quality to the breath sounds. The percussion note is less dull on the left than it was this morning. Weakness of the muscles of degluti- tion is very marked. September 16. The patient is much worse this morning. She is pale with a bluish tinge on the lips and general duskiness. The breathing is shallower and very rapid. The patient is more apathetic. The sounds in the chest are chiefly squeaks and coarse rales. It seems now like a generalized bronchitis of the larger tubes. She coughs occasionally, a loose cough. About an hour later, the patient suddenly became much worse. The respira- tion was shallow, heart rapid and weak, and death followed. The heart con- tinued to beat for some minutes after respiration ceased. Spinal fluid removed post mortem: about 6 c.c. of clear limpid fluid; cell count, 118.8 per c.mm.; globulin, slightly +; sugar, +. CASE 30. John A., age, 13 months. New York City. Admitted, October 29, 1911. Died, November 4, 1911. Diagnosis. — Acute poliomyelitis, bronchopneumonia. Family History. — Negative. Habitat: the family lives in a rather dirty tenement on East 17th Street. They have three rooms. There are about twenty children in the house. No sickness of any kind is known in the house or neigh- borhood. There are no lame children in the neighborhood. Past History. — The child has never had any illness. Present Illness.- — Five days ago, Tuesday, October 24, the baby seemed some- what ill. He was quiet and would not play. The mother gave him castoria and on Wednesday he seemed perfectly well again. On Thursday he again seemed ill and was very quiet. He was worse on Friday and stayed in bed all day. That night, that is, thirty-six hours ago, the mother noticed that he did not move his legs. Yesterday he was no better and last night it was noticed that he preferred to lie with his head well back. This morning, Sunday, a doctor was called in and diagnosed the case as poliomyelitis. There has been no cough, diarrhea, constipation, or sweating, no nervous excitement. The child has not been very cross and has cried very little. There has been no stupor. Physical Examination. — The patient is a pale, but healthy looking child, who lies quietly on his back. He is not very drowsy but becomes fretful and whines if handled. Eyes. — Pupils are equal and react normally. Nose.-^'No discharge. Ears.— Norma.!. Neck.— The neck is stiff. The patient can hold his head up in the sitting position, but prefers to let it fall back. Superficial lymph nodes. — The posterior cervical, axillary, and inguinal nodes are palpable. Many are enlarged. Thorax. — Well formed; respiratory movements normal. Heart.— Rapid but normal. Abdomen.— Not distended, no tenderness. Several small but distinct nodules can be felt in the central part of the belly. They do not feel like fecal masses and strongly suggest enlarged lymph nodes. Liver and spleen are not felt. Extremities.— Upper : there is distinct weakness of the right deltoid. Lower: there is complete flaccid paralysis of both lower extremities. Knee jerks Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 177 and Achilles reflexes are absent on both sides. There is no Babinski reflex. Kernig manipulation is not resisted but causes pain. Surface.— There are numerous small scaling spots on the forearms, and over the legs are many pink dull spots about S to lo mm. in diameter. They look like healed impetigo. There is also a smaller, more punctate eruption over the forehead and a few papules on the face. Temperature. — ioi.6° F. October 29. Lumbar puncture today yielded a clear fluid apparently under somewhat increased pressure. Cell count, 90 per c.mm.; lymphocytes, 92 per cent. ; polymorphonuclears, 6 per cent. ; large mononuclears, 2 per cent. ; globulin, o; sugar, ++ (quick reduction). October 30. The child is in good condition. He has considerable pain on moving the neck and legs. The left side of the mouth does not move quite so much as the right side does when the child cries. The left eye does not close so tightly as the right when the child cries. Lungs : there are generally scattered rales and a few piping sounds both anteriorly and more especially posteriorly. The child has a distinct grunting expiration at times. The temperature rose this morning to 102.2° F. October 31. There are rales all through both sides of the lungs. In the right upper back the breath sounds are a little harsh. The upper right front is less resonant. Rales are everywhere coarse and bubbling. November i. Both sides of the chest are full of moist bubbling rales. The child looks badly. Respiration is almost wholly thoracic. There is inspiratory retraction of the abdominal wall, but when the thorax is compressed, the abdom- inal wall acts in a way that seems to indicate some weak diaphragmatic action November 2. There are not so many moist bubbling rales this morning, but numerous squeaks. There is a good deal of mucus in the throat, and the child frequently gives a loose bubbling cough. There is very definite and almost complete weakness of the diaphragm. The child looks pale and possibly very faintly dusky. The weakness of the right deltoid has advanced to complete paral- ysis of practically the whole extremity. Only weak action of the muscles of flexion of the fingers remains. Possibly the left deltoid is also weak. The temperature was 101° F. at noon. November 3. The child has a high temperature this morning. Both sides of the chest are full of rales, coarse and bubbling. The diaphragm is hardly work- ing at all. The child looks very badly. The temperature is 104.4° F. P. M. The child has been out of doors all day. The physical condition is un- changed except that there are, if anything, fewer rales in the chest. The pulse is good. November 4. Last evening the child looked rather badly, but the pulse was of good quality and not very rapid. When seen at 2:00 a. m. the condition was un- changed. At 6:00 A. M. just after the nurse had felt the pulse and found it unchanged, the child suddenly died. CASE 31. Max G., age, 4J^ years. New York City. Admitted, October 18, 1911. Dis- charged, November 11, 1911. Result, improved. Diagnosis. — Acute poliomyelitis. Family History. — Negative. Habitat : the family lives in an eighteen family tenement. The house is new and is clean and airy. There are cockroaches, but Digitized by Microsoft® 178 A Clinical Study of Acute PoUomyfilitis. no other parasites in the house. The family have no cats or dogs. The father knows of no possibility of contact. Past History. — The child has always been well and strong. Present Illness. — On Sunday morning, October 15, three days ago, the child was perfectly well. That evening he had a headache and a little fever. The next morning he was feverish and vomited. Since that time he has been in bed. Monday evening the child had pain on moving his neck. He has not sweat much and has had no convulsions. Bowels and urination have been normal. On the first day of his illness the child was very drowsy, but he has been getting brighter. On Monday, two days ago, it was noticed that he was unable to move his eyes so as to look downward. He could close the eyes and move them normally in other directions. No other muscular weakness has developed. The child swallows normally but eats little. He has had fever each night. Physical Examination. — The patient is a well built, rather thin boy, lying on his left side with his legs curled up. Both eyes are partly closed, leaving a slit about 0.5 cm. in width in which the sclera and lower edge of the cornea of the up- turned eyes are visible. The child mutters from time to time, but it is difficult to understand him. He responds weakly to his name and answers simple questions, but he is very drowsy and when left alone lies in a semistuporous condition. The skin is hot and dry. The face is symmetrical, is not flushed, and there is no rash. Eyes. — The eyelids close normally when the patient is told to close the eyes. When let alone his eyes are held closed. There is marked photophobia. The pupils are equal and react quickly to light and accommodation. Both eyes move upward, and to the right and left normally, but neither eyeball can be made to look downward. He cannot see anything below the level of the eye. Th'ere is no strabismus. He can count his fingers quickly and correctly. Ears. — No discharge, no tenderness over the mastoids. Nose.—No discharge or excoriation. Mouth.— The lips and teeth are dry. The mouth is held partly open. The tongue is slightly coated, protrudes straight and for a good distance. Boti tonsils are enlarged and ragged, but not reddened. The pharynx is not red. Superficial lymph nodes. — There is moderate enlargement of the glands in the neck, axillae, and groins. Neck.— The neck is not retracted but it is held stifHy, and resists all attempts at flexion. Chest.— Well formed, symmetrical, moves normally with respiration. There is no rosary. Lungs.— Clear throughout on auscultation and percussion. Heart.— Not enlarged, regular, sounds of good quality. The pulmonic second is louder than the aortic second. A soft systolic murmur is heard over the precordium. Abdomen.— Fnll, soft, tympanitic, no masses or tenderness. Abdominal reflexes are active. There is no tache cerebrale. The abdominal wall moves normally with respiration. Abdominal muscles are strong. Cremasteric reflexes are active. Extremities.— Movements are normal and strong on both sides. Knee jerks on both sides are active when obtained, but are hard to obtain. Achilles reflexesi are absent on both sidfes. Kernig's sign: when the legs are extended a little more than a right angle, he complains of pain and tightens up his hamstrings. The Babinski test is unsatisfactory, first an extension and then a flexion. Oppenheim test: a slight but suggestive extension of the big toe on both sides was obtained. There is no tenderness on pressure over the' legs. Both arms move strongly and normally. Arm reflexes are not obtained. Temperature. — 104.2° F. Digitized by Microsoft® Francis W.Peabody, George Draper, and A. B.Dochez. 179 Spinal fluid: clear, colorless fluid; cell count, 61.1 per c.mm.; differential count of 200 cells : polymorphonuclears, 22.9 per cent. ; mononuclears, 78 per cent. ; globulin, o; sugar, slightly +. October 19. The patient lies with a peculiar expression in his eyes like a fixed stare, but he says he feels much better than yesterday. He follows an object with his eyes until the object is moved downwards. Then he says, "I can't look down." There is slight external strabismus of the left eye. The pupils react normally. There is no paralysis of upper or lower extremities. The knee jerks are hard to obtain, but when they appear they are distinctly increased. Achilles jerks are both present. The Babinski reflex on the right is distinctly suggestive. The Oppenheim reflex is positive. There is marked ataxia of arms and legs. The patient contracts the hamstrings, and resists extension of the leg when Kernig manipulation is attempted.. It is apparently quite painful. Blood count : leukocytes, 13,000 ; differential count of 200 cells : polymorpho- nuclears, 51.5 per cent. ; lymphocytes, 37 per cent. ; large mononuclears, 7 per cent. ; transitionals, 4.5 per cent. October 20. Spinal fluid : clear watery ; cells, 320 per c.mm. ; sugar, + ; globulin, very slightly +. Smear : a few red cells ; polymorphonuclears, 66 per cent. ; mononuclears, 34 per cent. ; no organisms seen. Note by Dr. Schirmer : " Position of the eyes when the boy looks in the distance is slightly divergent. Motion to the right and left side, and upward, is possible to physiological limits. In looking downward there is a marked restric- tion which is equal in both eyes. They can be moved downward to about 25° below horizontal. When the boy looks at a distance of one meter at my finger and I move the finger toward him, he is not able to converge at all. One of the eyes begins to deviate, and the movement develops into an associated one to one side." October 21. His condition is about the same. The child can look down a little better. He is irritable and wants to be let alone. When he is asleep he has frequent jerky movements of the arms. Reflexes of the legs are the same as yesterday except that the knee jerks and Achilles reflexes are both more active. October 23. The child is much better. There is slight strabismus (external on left?). The child can look down slightly better than before, especially with the right eye. Knee jerks are very active, Achilles reflexes active, Babinski negative, Oppenheim suggestive on both sides. Kernig's and neck signs are less painful. Spinal fluid: 8 c.c. of clear limpid fluid; pressure not increased; cells, 6 per c.mm. ; globulin, normal ; sugar, -j-. October 25. Eye grounds are negative. October 26. Spinal fluid: 10 c.c. of clear, watery, colorless fluid; pressure not increased; cells, 25 per c.mm.; mononuclears, +; globulin, very slightly -f ; sugar, +. October 31. Spinal fluid: 20 c.c. of clear, non-opalescent, watery fluid; cells, II per c.mm.; mononuclears, -f-; globulin, very slightly -f. November 4. The patient walked today. He showed a peculiar unsteadiness which at first looked like ataxia. On close examination, however, there is seen to be a distinct element of spasticity in the gait. The knee jerks are both exag- gerated. The Achilles jerks are hard to obtain and certainly not exaggerated. The eye condition is unchanged. The patient cannot converge. Digitized by Microsoft® 180 A Clinical Study of Acute Poliomyelitis. November li. The general condition is excellent. The patient's gait is now quite steady. Eyes : the tendency is for him to roll his eyes up, but he can move them both down almost normally. There is a slight external squint of the left eye. He does not converge. He seems to focus with his right eye, and if this is closed, he has to rotate the left eye inward in order to see an object. Both knee jerks are exaggerated, both Achilles jerks are nearly absent, abdominal and cremasteric reflexes are very active. Kernig manipulation is still painful. Oppenheim and Babinski tests are negative. CASE 32. Patrick T., age, 23 months. New York City. Admitted, October 4, ipn. Dis- charged, October 15, 1911. Result, improved. Diagnosis.— Acute poliomyelitis. Family History.— One brother, aged five years, had tonsillitis seven days ago and now has a cold in the head. He has had no muscular weakness or drowsi- ness. One sister, aged four years (Hannah T.), was admitted yesterday to Ward I, with poliomyelitis. Another sister, aged three years, had a cold one week ago, lost her appetite and was drowsy for two days, but is now perfectly well. She has had no muscular weakness. A third sister, eight weeks old, is healthy. Habitat: the family lives on Lexington Avenue in a fiat; they have five rooms, second floor front. The light and air are good. The mother and father, the sister with poliomyelitis, and the patient slept in the same room, the patient sleeping in a crib by himself and the sister in bed with the father and mother. The other three children sleep in a room together. There are flies, mosquitoes, bedbugs, and roaches in the house. The mother knows of no similar illness in the neighborhood. Past History.— The patient has always been a strong healthy child. Present Illness. — October 3, two days after the onset of the sister's illness, the mother noticed that the child was drowsy. This morning she noticed that he was " shaky " in his legs and could not rise from a sitting position. When placed on his feet he could walk fairly well, but dragged one leg. He has been able to use his arms well, and can feed himself. The mother has noticed no fever, but drowsiness has continued, and the child has been irritable. There has been no vomiting, no convulsions, and no retraction of the neck. Bowels and urination have been normal. The child had a cold and discharge from the nose one week ago, but it lasted only two days. Physical Examination. — The patient is a well nourished, sturdy child. He is drowsy but can be easily awakened and then becomes irritable. On being let alone he quickly goes to sleep again. Head. — Well formed, forehead slightly prominent. Face. — Symmetrical in repose, not drawn to either side on crying. Both eyes can be closed. Eyes. — Conjunctivae and scleras are clear. Eye slits seem equal. There is a tendency to keep the eyes closed and when open to hold them away from the light. External ocular movements are good, no strabismus. Pupils are equal, moderately dilated, and react rather slowly to light Ears.— No mastoid tenderness, no discharge. External ear, and meatus on the left side are reddened. Drums on both sides are obscured by wax. Mouth. — Lips and mucous membranes are of fair color. The tongue has a heavy yellowish white coat. Pharynx and fauces are red and injected. The tonsils are large and irregular; no exudate. Neck.— There is no retraction of the neck. The head is Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 181 easily held erect. There is no muscular weakness. The child resists anterior flexion slightly. Superficial lymph nodes. — The cervical, axillary, and inguinal glands are all easily palpable. Chest. — ^Well formed, expansion good, both sides move equally in respiration, diaphragm active. Lungs. — Clear on ausculation and percussion. Heart. — Action not especially rapid, sounds well heard, regular, no murmurs. The heart is not enlarged. Abdomen. — Soft, moves well with respira- tion, no masses or tenderness, no bulging. Abdominal muscles are strong. Extremities. — Upper : arm movements are normal, muscles show no weakness. Lower: the legs can be moved in all directions. The child stands alone and can walk well. The legs can be fully flexed on the abdomen without causing pain. The child, however, shows some irritability on being handled in this way. Reflexes. — Knee jerks, Achilles, and abdominal reflexes are active. Babinski and Kernig reflexes are absent. Temperature. — ioo.6° F. October 4. Spinal fluid: 35 c.c. of clear limpid fluid; pressure definitely in- creased (child crying somewhat) ; cells, 94 per c.mm. ; mononuclears, 93 per cent. ; polymorphonuclears, 7 per cent. ; globulin, o ; sugar, +. October S- Blood count: leukocytes, 15,000; differential count of 200 cells: polymorphonuclears, 52.5 per cent.; lymphocytes, 31.5 per cent.; large mono- nuclears, 13.5 per cent; transitionals, 1.5 per cent.; basophiles, 0.5 per cent.; eosinophiles, 0.5 per cent.; stimulation form, 0. October 8. There is no evidence_of paralysis. Reflexes are present and active in the legs. The child can walk and stand well, but his gait is rather wobbly. He is irritable and cries a good deal, but it seems to be temper chiefly. His legs appeared weak, and he fell when first put on the floor, but when he was started walking towards his sister, he could walk very well. October 15. The child walked very well this morning, several times up and down the hall. Both knee jerks and Achilles reflexes are active. The lungs are clear. The tonsils are both a little enlarged, but not especially red. Moving the legs (Kernig) seems to be painful still, though it is hard to distinguish the pain from temper. The child is discharged today.. CASE 33. Helen B., age, 6 years. Bergenfield, N. J. Admitted, September 2, 191 1. Dis- charged, September 17, 1911. Result, much improved. Diagnosis. — Acute polio- myelitis (abortive form). Family History. — Negative. Past History. — ^The patient has always been a healthy child and was never sick until July when she had whooping cough. She has always played with Helen K. (see case 29, page 174, who was taken sick on August 16 with acute poliomye- litis and died on August 21). Present Illness. — The child was perfectly well yesterday morning, September I. She came down to breakfast singing, ate her breakfast well, and played all the morning. She also ate a hearty lunch and played for a while in the after- noon. Later in the afternoon she complained of headache, which continued all the evening. She ate no supper, slept fairly well, was not very restless but seemed dull. .This morning she ate no breakfast. She has not vomited, but there was no movement of the bowels yesterday. No weakness of any extremity haS been noticed. She has had some pain in the back of the neck and forehead. Digitized by Microsoft® 182 A Clinical Study of Acute Poliomyelitis. Physical Examination.— The patient is a well developed little girl who lies quietly in bed and looks acutely sick. The face is flushed, the expression of the eyes is heavy and the lids are half closed or closed most of the time; she is very apathetic. Eyes.— The pupils are equal and react normally. Sclerse are clear, ocular motions normal. Nose.— No discharge. Face.— There is no weakness of the face muscles. £ow.— Normal. Mouth.— Buccal mucous membranes are clear. The teeth are in fair condition. No Koplik spots. The tongue has a very light greyish coat. Pharynx and tonsils are slightly reddened. The latter are large, especially the right. Superficial lymph nodes.— The posterior cervical, submental, axillary, and inguinal nodes are palpable. Neck.— Not stiff. Thorax. — Well formed, respiratory motions are normal. Lungs. — Clear. Heart. — Rapid, sounds normal, action regular. Abdomen.— Not distended, soft, no tenderness, no masses. Extremities. — Upper: normal, no tenderness. Lower: there is good power in all the muscles, no tenderness. Kernig manipulation causes no pain. Knee jerks are very active on both sides; crossed adductor reflex is obtained on tapping the left patellar tendon. The Achilles reflex is also active, the Babinski reflex negative on both sides. Back. — No weakness, no pain or tenderness. Surface.— There are several fresh bruise marks over the legs. Temperature. — 103.8° F. September 2. Blood count : leukocytes, 8,800 ; differential count of 200 cells : polymorphonuclears, yj per cent.; lymphocytes, 17.5 per cent.; large mono- nuclears, 0.5 per cent. ; transitionals, 4 per cent. ; stimulation form, i per cent. Spinal fluid : 20 c.c. of almost clear limpid fluid. There is a faint suggestion of opalescence ; cells, s per c.mm. ; polymorphonuclears, 20 per cent. ; mononuclears, 80 per cent.; globulin, o; sugar, -|-. September 3. The patient slept well. Her temperature is 99.1° F. This morn- ing the temperature has fallen to 99° F. She is still rather listless but much less dull than yesterday. She has no headache. The knee jerks are still very active. The patient says she feels much better. She vomited after taking citrate of magnesia. In the afternoon the mother came and finding the child's temperature normal insisted on taking her home. She was advised to leave the patient but would not. The temperature was 98.7° F. The patient showed some unsteadi- ness on her feet but no definite weakness. About an hour later the mother returned in a taxicab with the child. On the way to the train she had com- plained bitterly of her head and vomited. The child begged to be put in bed. She looks greatly prostrated. There is a distinct tendency to keep the head back, and she assumes the position on her side so as to facilitate this. The neck is very slightly stiff, and an attempt to flex it causes pain. The Kernig manipu- lation causes pain about the knees. The knee jerks are still exaggerated. Spinal fluid: about 2 c.c; cell count, 62 per c.mm.; polymorphonuclears, 1 1.3 per cent; mononuclears, 88.7 per cent; globulin, slightly + Blood count: leukocytes, 11,200; differential count of 200 cells; polymorpho- nuclears, 79.5 per cent. ; lymphocytes, 14.5 per cent. ; large mononuclears, 0.5 per cent; transitionals, 4.5 per cent.; basophiles, o; eosinophiles, 0.5 per cent; stimulation form, 0.5 per cent. September 4. Temperature: 99-i° F- The patient seems a little better this morning. She is still apathetic and prefers to lie on her side. The neek resists flexion slightly, and the attempt to flex it causes pain in the occipital region. Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 183- Kernig manipulation causes slight pain in the knee. Knee jerks are not quite so exaggerated as before, but are still very active. No weakness is found in any muscles. The patient sits up well. The tongue has a heavy yellowish grey- coating. p. M. She has been drowsy and sleepy most of the day. When her father came the child paid hardly any attention to him and showed no signs of pleasure. She answered his questions only by nods and shakes of the head. As soon as he left the room she became drowsy again. At 3:00 p. m. the knee jerks are found, to be so much less active than before that several blows of the hammer are required to elicit the jerk. They are fairly active when they do respond. No- weakness is found. The neck is a little less stiff. 10:20 P. M. The patient is sleeping, but half waked during the process of eliciting knee jerks. They are less easily obtained than when last noted. When they respond it is with about normal activity. The stiffness of the neck late this- afternoon (about S '-^o p. m.) had almost entirely gone. September 5. The patient slept well this morning. She seems brighter, though, still not very communicative. She has no headache. The neck is not stiff. Both knee jerks are active. She still prefers to lie in bed and does not feel energetic. The von Pirquet reaction made two days ago is positive, a raised. urticarial-like area about i cm. in diameter, ' and red. The temperature dropped to normal last night. This morning it is 99° F. again. p. M. The patient continues to be somnolent and takes very little interest in her surroundings. There is no change in her physical condition. It is possible- that the right palpebral fissure is somewhat narrower than the left. Examination of the eye grounds reveals no abnormality. September 6. The patient is a little brighter this morning but still prefers to- lie in bed. The tongue has almost entirely cleared. The neck is a little stiff. "Signe de la nuque " is present. The left knee jerk is obtained on reinforce- ment only, right knee jerk normal. Spinal fluid: aboutSc.c. of not quite clear, slightly opalescent fluid with faintly yellowish tinge ; cells, 59 per c.mm., mostly mononuclears ; globulin, slightly + ;. sugar, +. In the wet preparation for counting, a large phagocytic cell was seen- containing five small mononuclears. Blood count: leukocytes, S,6oo; differ- ential count of 200 cells : polymorphonuclears, 68.5 per cent. ; lymphocytes, 22- per cent.; large mononuclears, l.S per cent.; transitionals, 6 per cent.; basophiles,. 0; eosinophiles, I per cent.; stimulation form, i per cent. This evening the patient is somewhat brighter but continues to answer ques- tions by shakes or nods and occasionally a monosyllabic reply. She is still drowsy. There is no change in her physical condition. * September 7. The patient seems better this morning. She sits in a chair- easily, and also walks well, though perhaps with a little uncertainty. She con- tinues to be most unresponsive. Her appetite is better, however, and she ate her supper last night, and breakfast this morning with a relish. There is still slight rigidity of the neck and "signe de la nuque.'' The knee jerks are the same as- yesterday. September 11. The patient is considerably better. She talks more and' is losing her apathy. "She still does not feel much like sitting up. The knee jerks, are active. Spinal fluid: 20c.c. of clear limpid fluid; pressure not increased; celL count, 4 per c.mm. ; globulin, very slight haziness (normal) ; sugar, +• Digitized by Microsoft® 184 A Clinical Study of Acute Poliomyelitis. September 13. Blood count: leukocytes, 11,800; differential count of 200 cells: polymorphonuclears, 78.5 per cent.; lymphocytes, 14.5 per cent.; large mononuclears, 4.5 per cent.; transitionals, 3.5 per cent.; eosinophiles, 0.5 per cent.; basophiles, o; stimulation form, 0.5 per cent. September 15. While the patient is better in every way, she still gives the impression of being a little apathetic. Her appetite is poor. Besides the un- steadiness that one would expect on first getting up, her manner of walking gave distinctly the impression of spasticity. This was quite in accord with the generally increased tone of the legs throughout her illness and with the exag- gerated knee jerks. This morning the knee jerks are very much exaggerated. September 17. The patient has been up in a chair for the past two days and was walking yesterday. She walks much more steadily. On physical examination nothing abnormal can be found but the still somewhat exaggerated knee jerks. The neck has no trace of stiffness and the " signe de la nuque" is gone. She feels well and is discharged. CASE 34. Clara T., age, 8 months. New York City. Admitted, August 22, 191 1. Dis- charged, August 24, 191 1. Result, not improved. Diagnosis. — Acute t)oliomyelitis. Family History. — Mother and father are living and well. There is one other child in the family, a twin sister of the patient, who now has poliomyelitis in this hospital. Past History. — The child has had no illness previous to the onset of the present trouble. Present Illness. — The child was perfectly well until yesterday evening, August 21. At this time the mother noticed that she was rather irritable and objected to being handled. She vomited several times, and had a slight cough. Today she has again vomited several times and at four o'clock this afternoon her tempera- ture was 102° F. When the child was examined in the receiving ward, handling of the right leg caused loud screaming. Physical Examination. — The patient is a well nourished baby with good color, bright alert expression, and does not look sick. She lies quietly, and is sometimes playful. During examination she regurgitated suddenly and without effort. Occasionally she coughs. Eyes. — Pupils are equal and react normally. Ocular motions are normal, no squints. Ears. — Normal. Nose. — Normal. Mouth.— Buccal mucous membrane is clear. Tonsils are a little enlarged, pharynx slightly reddened. ATecA:.— Distinct rigidity. Superficial lymph nodes.— Ihc posterior cervical and left axillary nodes are palpable. Thorax.— WeW formed, respiratory motions normal, //^arf.— Normal. LM«gj.— Normal. Abdomen.— "^tW rounded and prominent, soft, moves properly with respiration. The spleen is easily felt. Extremities.— Vp^tr : there is possibly a shade less strength in the right shoulder than in the left, but this is very indefinite. At times there is a distinct stiff shaking of the arms. Lower: knee jerks absent on the right, very faint reac- tion on the left; Achilles reflex absent on the right, present on the left; Babinski test negative on both sides; Kernig's sign: on the right side no resistance but some distress, on the left slight resistance. The left leg is moved about in a very active manner. The right, however, is not moved nearly so much, practically not at all spontaneously. When prodded, there is some move- Digitized by Microsoft® Francis W. Peabody, George Draper, and A. B. Dochez. 185 ment to withdraw the extremity, but this is chiefly in the lower leg muscles, and very little or not at all in the thigh. Surface.— T)\tr^ is a faint erythema over the upper part of the chest anteriorly. Over the inner end of the right eyebrow is a small superficial moist ulceration, sharply circumscribed and looking much like a collapsed water blister. Temperature. — 102.6° F. August 22. Spinal fluid : 30 c.c. of slightly greyish opalescent fluid ; pressure at first much increased (child crying) ; later, slightly increased ; cells, 990 per c.mm. ; 95 per cent, polymorphonuclears. Smear: polymorphonuclears, 85.5 per cent.; transitionals, 4 per cent. ; mononuclears, 10.5 per cent, (including probably both endothelial and lymphocytes, these cells being destroyed beyond recognition) ; globuHn, +; sugar, + +. Blood count: leukocytes, 35.6oo; differential count of 200 cells : polymorphonuclears, 32 per cent. ; lymphocytes, SS-S per cent. ; large mononuclears, i per cent.; transitionals, 9 per cent.; basophiles, 0; eosinophiles, I per cent.; stimulation form, 1.5 per cent. August 23. Spinal fluid : about 7 c.c. The first cubic centimeter was clear and slightly opalescent. This was used for cell count and smear; The smear con- tained a few red blood corpuscles, with great excess of mononuclears. Cell count, 627 per c.mm. ; polymorphonuclears, 20 per cent. ; mononuclears, 80 per cent. ; no test for globulin, nor for sugar. On admission the child was irritable and cried a great deal. The knee jerks and Achilles jerks on each side were exaggerated. Both lower extremities were strong and active. This evening the left knee jerk is gone. The left Achilles jerk is very faintly present. The child cannot move the teft thigh now, so that both lower extremities are affected. The flexors and extensors of the feet are still acting, but are weak. The child is rather more fretful this evening. August 24, This morning there is no further advance of the paralysis, but both lower extremities are flaccid, save for some slight motion in the flexors and extensors of the feet and toes. The Achilles jerk on the left is gone. The arras are active and strong. The temperature has risen again to 102.8° F. The child looks bright, but is perhaps too alert and nervous. She is still inclined to be irritable if handled. If a sudden noise occurs, she blinks rapidly for several seconds and starts. Blood count: leukocytes, 23,200; differential count of 200 cells : polymorphonuclears, 49 per cent. ; lymphocytes, 33.5 per cent. ; large mono- nuclears, s per cent. ; transitionals, 9.5 per cent. ; basophiles, 0.5 per cent. ; eosinophiles, 0.5 per cent. ; stimulation form, 2 per cent. This afternoon the child seems to be in about the same condition. It is possible that the patient is slightly more somnolent and does not show the nervous activity of the upper extremities that she did yesterday. Spinal fluid : a few cubic centimeters of slightly turbid, opalescent fluid were obtained; cell count, 1,221 per c.mm. In the wet count there are many very large phagocytic mono- nuclear cells with vacuoles; mononuclears, 92 per- cent. ; globulin, -|- (moderate flocculent precipitate) ; no test made for sugar. The father insisted on taking the child home this afternoon. Digitized by Microsoft® 186 A Clinical Study of Acute Poliomyelitis. EXPLANATION OF PLATES. Plate i. Fig. I. Interstitial meningitis in the anterior fissure of the cord, i ming perivascular infiltration of the gray matter (human). Fig. 2. Infihration with small round cells in the perivascular lyr -(monkey). Plate 2. Fig. 3. Diffuse areas of hemorrhage in the gray matter of the core Plate 3. Fig. 4. Neurophages in nerve cells of the anterior horn (monke; Fig. 5. Extensive infiltration of the gray matter of the cord (hu; Plate 4. Fig. 6. The inflammatory process is seen extending throughout :anterior horn (monkey). Low power. Fig. 7. Drawing of the lumbar cord of a monkey showing exter stitial meningitis and beginning perivascular infiltration. Plate 5. Fig. 8. Perivascular and diffuse round cell infiltration in tl '(monkey). Plate 6. Fig. 9. Cervical ganglion, showing advanced inflammatory reactii Plate 7. Fig. id. A spinal ganglion showing diffuse inflammatory process Tiing necrosis of the nerve cells (human). Plate 8. Fig. II. Neurophages in a spinal ganglion (monkey). Fig. 12. Human lymph node. The pale centres of the nodules 1 hy large endothelial cells. Low power. Plate 9. Fig. 13. Human liver. Drawing showing necrosis of the live; accumulation of lymphoid and polynuclear cells. High power. Fig. 14. Electrocardiogram of the arrhythmia regularly seen i: •cases. Plate 10. Fig. 15. Photograph of a case with profound stupor, showing i; pression. The paralyzed left arm has been flung over by the shrug; .shoulder. The retraction of the neck is also apparent. Digitized by Microsoft® Francis W. Peaiody, George Draper, and A. B. Dochez. 187 Fig. i6. A case of intercostal paralysis, showing protrusion of the abdomen by contraction of the diaphragm and concomitant retraction of the thorax. Fig. 17. Front view of patient shown in figure 2 with intercostal paralysis. Plate ii. Fig. 18. Paralysis of the lateral abdominal muscles. Bulging is produced by crying. Fig. 19. Paralysis of the lateral abdominal muscles and right rectus. Bulg- ing is caused by the attempt to sit up. Plate 12. Fig. 20. The only evidence of paralysis is in the upper distribution of the seventh nerve. This was a profoundly stuporous case. Plate 13. Fig. 21. Residual facial palsy in a case with profound stupor. Fig. 22. The same as figure 21. 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