Columbia JBnibtvsit]^ ^^^^ in tiie Citp of iScttj Horfe CoUese of Ij^fivsiciani anb ^urseonsc 3^eference i^itirarp POLIOMYELITIS IN ALL ITS ASPECTS BY JOHN RUHRAH, M.D. PROFESSOR OF PEDIATRICS IN THE UNIVERSITY OF MARYLAND MEDICAL SCHOOL AND THE COLLEGE OF PHYSICIANS AND SURGEONS; CONSULTING PEDIATRIST TO THE BAYVIEW HOSPITAL AND TO THE CHURCH HOME AND INFIRMARY; VISITING PEDIATRIST TO THE MERCY HOSPITAL, THE HOSPITAL FOR THE WOMEN OF MARYLAND, ROBERT GARRETT HOSPITAL FOR CHILDREN, NURSERY AND child's HOSPITAL, AND TO THE CHILDREN'S HOSPITAL SCHOOL ERWIN E. MAYER, M.D. FIRST LIEUTENANT IN THE MEDICAL OFFICERS* RESERVE CORPS, UNITED STATES ARMY; FORMER SENIOR RESIDENT PHYSICIAN AT THE MERCY HOSPITAL; INSTRUCTOR OF MEDICINE IN THE UNIVERSITY OF MARYLAND MEDICAL SCHOOL AND COLLEGE OF PHYSICIANS AND SURGEONS ILLUSTRATED WITH 118 ENGRAVINGS AND 2 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 1917 Copyright LEA & FEBIGER 1917 THIS VOLUME IS INSCRIBED TO MISS ANNA MARIE SCHIVE AND TO MISS ELIZABETH M. STONE SUPERINTENDENT OF THE NURSERY AND CHILD 's HOSPITAL OF BALTIMORE EST APPRECIATION OF THEIR MANY YEARS' FAITHFUL AND EFFICIENT SERVICE IN THE NURSING AND CARE OF SICK CHILDREN X- Digitized by tine Internet Arciiive in 2010 witii funding from Op# Knowledge Commons http://www.archive.org/details/poliomyelitisinaOOruhr PREFACE In the preparation of this volume the authors have endeavored to collect the various facts concerning the disease as far as they are known at the present time and to give briefly such theoretic consid- erations as may seem to be either of interest or importance. They have attempted to gather together in one volume the information which they themselves have wanted on the subject. Ihe literature of poliomyelitis has grown to enormous proportions and there are over three thousand articles which are being added to daily. Throughout the text references have been made to the articles which have been consulted, but no extensive bibliography has been added. There is, at present, no adequate account of the disease in one volume, although there are many excellent monographs featuring one or more phases of the subject. To get a satisfactory account of the disease one must do extensive reading which requires not only time, but access to a well-stored library. If this little volume supplies even in a small measure what seems to be a need, the authors will be amply requited for their labor in preparing it. To save the necessity of cross reference and for the convenience of those who may wish to study their cases carefully tests for the examination of the cerebrospinal fluid and a chapter containing the figures and tables illustrating the various facts in the diagnosis and localization of nervous lesions have been included. The authors have many aclmowledgments to make and wish to express their thanks to all who have helped them. First of all the many colleagues whose works have been used. They have endeav- ored to indicate in every instance the source of their information. In this regard they are particularly obligated to ]\Iiss W. G. Wright, whose excellent muscle tests and exercises in Lovett's monograi)h must, of necessity, serve as a model for all who attempt to tlescribc in detail these two important features in the treatment of the VI PREFACE disease. They are also indebted to various authors for illustra- tions and to Dr. William S. Baer and Miss Tabb, of the Children's Hospital School, to Dr. Mathias Nicoll, Jr., of the New York State Department of Health, for others, and to Mr. Henry Sharpies for photographing the muscle tests and exercises ; to the Surgeon- General of the United States Public Health Service, the officials of the Library of the Surgeon-General of the United States Army, the Librarians of the Medical and Chirurgical Faculty of Maryland, the Commissioners of Health of New York City, and particularly to Dr. Charles Bolduan, of the Department of Health of the City of New York, and Dr. Robert W. Lovett, of Boston, for many favors and to Dr. Albertus Cotton, for suggestions regarding the chapters on orthopedic and surgical treatment, and to all the others who have generously aided in the work. The authors are especially indebted to Miss Erna Ball for the work which she has done on the manuscript and for preparing the index. J. R., E. E. M. Baltimore, July, 1917. CONTENTS. CHAPTER I. History of Poliomyelitis 17 CHAPTER II. A Conception of the Disease 30 CHAPTER III. Pathology 32 CHAPTER IV. The Nature of the Virus 40 CHAPTER V. Epidemiology 52 CHAPTER VI. The Synonyms and Classification 73 CHAPTER VII. Paralysis 93 CHAPTER VIII. Special Features and Symptoms 122 CHAPTER IX. The Technic of Lumbar Puncture 135 viii CONTENTS CHAPTER X. Diagnosis 144 CHAPTER XI. Prognosis 157 CHAPTER XII. Treatment 164 CHAPTER XIII. Orthopedic Treatment ' . . . . . 185 CHAPTER XIV. Operative Treatment 195 CHAPTER XV. Examination of Muscles and Muscle Training ...... 204 CHAPTER XVI. The Prevention of the Disease 253 CHAPTER XVII. Bibliography 264 CHAPTER XVIII. Some Anatomical and Physiological Reminders 265 CHAPTER XIX. Epidemics 277 POLIOMYELITIS. CHAPTER I. HISTORY OF POLIOMYELITIS. Poliomyelitis is one of the most interesting diseases from the standpoint of its history, inasmuch as it seems to be a disease of comparatively recent origin. In the history of most diseases there is a gradual shading off into the older \\Titers until the disease is lost in confusion of inaccurate descriptions, but with poliomyelitis, as with whooping-cough, the disease seems to have originated within comparatively recent times. The disease is so striking in its symp- tomatology, so devastating in its results, and produces such a deep impression on the popular mind that it does not seem possible that any very considerable epidemics could have happened in the countries in which there were physicians making records of what occurred. It is true that J. K. Mitchell has given a descripiton of a skeleton of an Eg^'ptian mummy with changes which were supposed to be due to poliomyelitis. Others have described similar deformities in sculptured objects and in paintings; but such deformities, we must acknowledge, might be due either to polio- myelitis or to other lesions of the nervous system occurring in early life. The first mention of the disease as we understand it today seems to have been by Michael Underwood in 1784, in the first edition of his treatise on the Diseases of Children. L'nderwood was one of the first licentiates in midwifery of the Royal College of Physicians of London, and he ^ecei^'ed an honorary diploma constituting him a doctor of medicine, and he was then admitted into this class of licentiates, together with other distinguished practitioners of mid- wifery in London, in 1784, the same year that his treatise on chil- dren was first published. Underwood was a skilful accoucheur and 1 Tr. Assn. Am. Phys., 1900, xv, 134. 18 HISTORY OF POLIOMYELITIS received great popularity from having attended the Princess of Wales in the year 1796, when the Princess Charlotte was born. He will live in the history of medicine, however, on account of the two pages that he devoted to a condition which he calls " the debil- ity of the lower extremities." Underwood's book on Diseases of Children was deservedly a very popular one and went through many editions, including several American editions, and it was translated and republished many times in Germany. The later editions of the book were edited by either Marshall Hall or Samuel Merriman, and the initialed note in some of the later editions as given below, shows that the collaborators did not always tend to improve the work. The most important part of Underwood's description is as follows: "Debility of the Lower Extremities.— This disorder either is not noticed by any medical writer within the compass of my reading, or is not so described as to ascertain the disease here intended. It is not a common disorder anywhere, I believe, and seems to occur seldomer in London than in other parts of the kingdom. Nor am I enough acquainted with it to be fully satisfied, either in regard to the true cause, or seat of the disease, either from my own obser- vation, or that of others, with whom I have corresponded, except in the instance of teething or of foul bowels; and I have not myself had an opportunity of examining the body of any child who has died of this complaint. I shall therefore only describe its symptoms, and mention the several means attempted for its cure in order to induce other practitioners to pay attention to it. "If it arises from teething, or foul bowels, the usual remedies should be employed; and have always effected a cure. But the complaint as often seems to rise from debility, and usually attacks children previously reduced by fever, seldom those under one or more than four or five years old. It is then a chronical complaint, and not attended with any affection of the urinary bladder, nor with pain, fever, or any manifest disease; so that the first thing observed is a debility of the lower extremities, which gradually become more infirm, and after a few weeks are unable to support the body. "When only one of the lower extremities has been affected the above means in two instances out of five or six entirely removed the complaint; but when both have been paralytic, nothing has seemed to do any good but irons to the legs, for the support of the limbs, and enabling the patient to walk. (It may be doubted DEBILITY OF THE LOWER EXTREMITIES 19 whether irons to the legs can ever be useful in a state (^f paralysis of the lower extremities. If the limbs are paralytic, how are irons to the legs to enable the patient to walk? — S. M.) At the end of four or five years, some have by this means got better in proportion as they have acquired general strength: but even some of these have been disposed to fall afterward into pulmonary consumption, where the debility has not been entirely removed." From this time on there were a few cases reported, including some by Shaw,^ w^ho thought that the disease bore some relation to weaning; and some \'ague paralytic conditions have been described by Jorg,2 Bartsch,^ Bruck,* and Hutin.^ On October 19, 1835, Dr. John Badham, of Worksop, Notts, sent to the London Medical Gazette an article entitled "Paralysis in Childhood: Four Remarkable Cases of Suddenly Induced Paraly- sis in the Extremities, Occurring in Children, without any Apparent Cerebral or Cerebrospinal Lesion." This was published Novem- ber 14, 1835.^ John Badham was the son of Professor Badham, quite a writer on medical topics in his day. He describes four cases: the first, Ann Hare, aged two years, who had a paralysis of her right leg. "The child had enjoyed uninterrupted health up to the evening of her attack, with the exception (if, indeed, it can be so called) of slightly augmented thirst and some drowsiness, now remembered by the mother to have preceded the seizure by two days. On the evening of August 13 the child was put to bed, having run about and amused herself as usual during the day. On the following morning her mother's attention was first attracted, in dressing her, to an unusual appearance of the eyes, which, as she said, appeared to be turned inward. (This is the first mention of cranial nerve involvement.) A new cause of apprehension presented itself in putting the child on her feet, when it was found she could not stand." On examination he noted that "her appearance at this time did not denote any disease — she was playing in her mother's lap, but on examination it was found that motion in the right leg was com- pletely destroyed, and in the left somewhat diminished, while 1 Nature and Treatment of the Distortion to which the Bones of the Spine and Chest are Subject, 1822. 2 Ueber Verkriimniungen des Menschlichen Korpers, p. 85. ' Ammon's Monatsschrift, Band ii, Heft 1, p. 7-1. * Casper's Wochenschrift, 1839, No. 32. ^ Sammlung zur Kenntniss der Gehirn und Riickenmarkskrankheitcn, von Nasse, Heft 2, p. 10. ^ London Med. Gaz., vol. xxxvii; vol. i for the Session 1835-1836, p. 215. 20 HISTORY OF POLIOMYELITIS sensation, perfect in the left limb, was impaired, without being suspended in the other." The child was treated with calomel and blisters and other things used in those days. " Under this treatment the drowsiness was removed in five days. On the fourth, indeed, from its adoption, the bell of the right eye became suddenly liber- ated from its constrained position; the other eye recovered more slowly a few days afterward. The exercise of the will over the affected extremity, though entirely abolished at first, has now par- tially returned, inasmuch as she no longer drags the limb after her, as she at first did, but projects or flings it forward with a jerk, the direction and force of which she seems not to have the slightest power to moderate or control. "My second case singularly occurred a few days afterward; its subject a little girl, also two years old, who had been seized, a week previously to my seeing her, with an equally sudden loss of the same extremity, which took place also during sleep, without any prior intimation." In this case there was also a palsied leg as the result. Case three was also a girl, aged two, who was found to have lost the use and a great portion of the sensibility of the left arm. "The limb is now, after a period of two months, hopelessly paralyzed and swings like a suspended object attached to the body." Case four, a little boy, aged two years and a half, in whom the left leg was paralyzed. Badham makes the following comments: "1. The extraordinary youth of the patients is to be noticed. It will be observed that the age in all the above cases correspond within a few months. "2. Although each case was either preceded by or ushered in by some apparent cerebral sjniptoms — viz., in two by drowsiness, in the others by an abnormal state of the pupil — yet "3. It is remarkable that in no one instance has the health been in any degree impaired. "4. If the case in which the remarkable strabismus occurred should lead us to suspect a cerebral complication, rather than a spinal one, there is other suspicion of congested, oppressed, or irritated brain." The first monograph on the subject, and indeed a very remark- able one, was the work of Jacob Heine. According to Baas the Heines were a family whose various members were intimately connected with orthopedic surgery. The family began with Georg von Heine (1770-1838), an ex-farrier, and the inventor of an exten- DEBILITY OF THE LOWER EXTREMITIES 21 sion bed; another member, Bernard, was the first to use osteotomy in straightening bones, while Jacol) von Heine (1709-1878) was an orthopedie surgeon of Cannstatt, a suburb of ^Stuttgart. I lis son Karl, afterward a professor in Prague, was also noted for his ortlio- BEOBACHTUNGEN ii b e r lialimungrszustande der untern Extre- mitaten iind deren Beliandliiiig^. J. Heine, Dr. der Mcdiciii uud Chirurgio, Giiindci- und Vorsteher dcr orlhopUdischen lleilaiuUll zii CaiinstadI a. N. Mit 7 Steindrucktafeln. Franz HcinrichKiihler. 1 8 4 O. Fic. 1. — Title pa^e of Heine's first monograph. pedic writings. Heine's monograph was published in 1840 under the title of Beohachtungen uber Ldhnungszustdnde der iiniern Extre- mitdten mid deren Behandlmig. It is a volume of 78 pages, with 7 lithographed full-page plates, showing 22 figures illustrating deform- 22 HISTORY OP POLIOMYELlfiB ities before and after correction, and a small exercising machine. He starts in with a description of cases which he has observed, including 14 cases of paraplegia, 7 cases of hemiplegia, and 6 cases of partial paralysis in which only one or more muscle groups were flfS Fig. 2. — Showing the remarkably good results obtained by Heine by orthopedic treatment. Picture on the left shows the condition of the patient on entrance and on the right on leaving the hospital. affected. After the description of his cases he takes up a consid- eration of the symptomatology, and gives in a very clear manner the most important features of the disease as we know them today. He made some special observations on the temperature of the DEBILITY OF THE LOWER EXTREMITIES 23 paralyzed extremities as compared to the unaffected members. Another chapter is devoted to the etiology, and there is one on the pathological anatomy. He also considers the subject of diag- nosis and prognosis, and devotes a considerable chapter to the Fig. 3. — Showing some other results on entering and leaving the hospital, also an arm case and a simple apparatus for exercising the legs. therapy, in which he recommends exercise and baths, the use of a simple device for exercising the legs, various simple surgical proce- dures to be followed by the use of apparatus well shown in some of his illustrations which we have reproduced. 24 HISTORY OF POLIOMYELITIS In 1860, twenty years later, a second edition of the book was published, a monograph of 204 pages with 14 plates. This time the authorship of the volume is given ^s Jacob von Heine, and the name is followed by a considerable list of titles and honors that Fig. 4. — Shows the use of orthopedic apparatus and the excellent results that were obtained. had been bestowed upon him. The book gives some further studies of actual cases and a review of the literature, together with valu- able chapters on diagnosis, prognosis, and therapy, and it is inter- esting to note the title of the monograph was changed to Spinale MEDICAL NOTES 25 KindcrJiiJwnnui (hifantile Spinal Paralysu). Heine's original monograph was followed by the appearance of a considerable num- ber of observations by various other writers. Henry Kennedy, M.K.I. A., published an article/ and subsequently, in ISoO,^ another on some of the forms of paralysis which occur in early life. Kennedy was a prominent Irish physician, a fellow of Kings and Queens College of Physicians in Ireland, and Temporary Physician to the Court Street Hospital. He does not mention Heine, and it is fair to presume he did not know about his work. He noted that temporary paralysis was of tolerably frequent occurrence and thought that the arm was more frequently paralyzed than the leg, but that in young infants the diagnosis of paralysis of the leg was more apt to be made. He recommended warm baths for the pain. West also wrote about the disease in the London Medical Gazette In 1845, and described it in his text-book of Diseases of Children in 1848. In France, Barthez and Rilliet described the disease in their remarkable work on the Diseases of Children, and there is a special article by Rilliet in which he called the disease the essen- tial paralysis of children.-^ They had an opportunity of making an autopsy, but did not notice any changes in the nervous system, and so called it the essential paralysis. In America the first epidemic was described by Colmer,^ 1843. This entire article is as follows: Medical Notes. By George Colmer. — Paralysis in Teething Children. — " While on a visit to the parish of West Feliciana, La., in the fall of 1841, my attention was called to a child, about a year old, then slowly recovering from an attack of hemiplegia. The parents (who were people of intelligence and unquestionable verac- ity) told me that 8 or 10 other cases of either hemiplegia or para- plegia had occurred during the preceding three or four months within a few miles of their residence, all of which had either com- pletely recovered or were decidedly improving. The little sufferers were invariably under two years of age, and the cause seemed to be the same in all — namely, teethitig." All these earlier writers ascribed the disease to teething or to weaning, except Heine, who recognized that he had to deal with a disease of the spinal cord. In 1855 Duchenne, of Boulogne, called it fatty infantile atrophic paralysis, and later he shortened the name to infantile atrophic paralysis. He gave an admirable ' Dublin Med. Press, September 29, 1841. 2 Dublin Quart. Jour. Med. Sc, ix, 85. 3Gaz. Med., 1851, p. 681. •Am. Jour. Med. Sc, 1843, v, 248. 26 HISTORY OF POLIOMYELITIS study of cases, and suggested the use of faradic electricity, both in prognosis and in treatment, and stated: "All the cases of infantile paralysis which I have seen where the faradic contractility was demonstrated and not lost and which could be treated with faradic electricity, within two years after the onset, have been completely recovered." In 1856 there was an excellent article by Chassaignac.^ He described it as a painful paralysis of young children, and in 14 cases only found one in the leg. He describes graphically the sud- den onset, the completeness of the paralysis, and the pain. The first historical period embraces the time from Underwood, in 1784, to Heine's second publication in 1860, and practically this might be shortened to include the time between Heine's two contri- butions. This was the period of the investigation of the clinical history, with little or no knowledge of the pathological processes involved. The second period, or the period of the study of the pathological anatomy, dates from 1863, and might be closed with the publication of Medin's article, which introduced the modern era of the understanding of poliomyelitis. There had been a number of autopsies made prior to 1863. Seeligmiiller^ gives a table of cases beginning with Hutin, in 1825. Hutin's findings are com- mented on at length by Heine. In this case both legs were par- alyzed, and from the eighth dorsal nerve downward there was a marked shrinking of the spinal cord to the thickness of an ordinary lead-pencil, and the spinal nerves were also atrophied. In 1829 Klein found a congestion of the pia around the roots of the left brachial plexus (quoted by Heine). In 1842 Longet^ described the findings in the case of a girl, aged eight years, whose right leg was paralyzed. He found an atrophy and a brownish discoloration of the lumbar and sacral nerves going to the sciatic. Fliess,^ in 1849, described a congestion of the meninges in the neighborhood of the roots of the arm nerves. These and several other observations of a negative character represent the pathological findings up to 1863, when von Reinecker and von Recklinghausen^ described an atro- phy and degeneration of the ganglion cells and nerve fibers of the anterior horns of the cord. In the same year Cornil^ described atro- phy of the anterior lateral columns and atrophy of the anterior ganglion cells. In 1864 Bouvier and Laborde and Cornil and 1 De la Paralysie Douloureuse des jeunes Enfants, Arch. Gen. de Med., 1856. 2 Gerhardt's Handbuch der Kinderkrankheiten, vol. v, Part I; second half, p. 15. 3Anat. u. Phy.siol. d. nerven System. ^ Jour. f. Kinderkr., xiii, 39. s Deutsch. Klinik, January 31, 1863. ^ Qaz. Med., 1864, p. 290. n MEDICAL NOTES 27 Laborde described cases in which they noted a sclerosis of the anterior cohimns and an increase in the connective tissue. In 1865 Prevost' noted the atrophy of the gray matter of the left anterior horns, and especially of the ganglion cells. In the following year, 18C6, Echeverria noted a diffuse myelitis and changes in the anterior horns and pigmentation. In 1870 Charcot and Joffroy- described the atrophy of the ganglion cells and of the anterior horns and the anterior nerve roots; and Parrot and Joffroy^ the atrophy of the ganglion cells and sclerosis of the anterior lateral columns. These observations were confirmed by Vulpian,^ who noted the atrophy and degeneration of the ganglion cells and nerve fibers, and by Roger and Damaschino,* who described foci and softening through- out the cord, together with atrophy of the ganglion cells and nerve fibers, sclerosis of the anterior columns and atrophy of the anterior roots. They also described degeneration of the bloodvessels. Others who confirmed these findings are Seeligmiiller, Lancereaux and Pierret, Leiden, Raymond, Demme, Schultze,^ and a few other workers, references to which will be found in Seeligmiiller's article or in the excellent article by Mary Putnam Jacobi.^ There was considerable discussion in the medical literature over the nature of the changes, Charcot believing it to be a primary atrophy and others having other views, which were argued back and forth at considerable length. The histological changes were studied by Roger and Damaschino and by Clarke and Schultze, but it was not until the time of Rissler^ that any definite studies were made upon the acute cases. Rissler studied 3 cases that died between the fifth and eighth days, and gave a very accurate description of the changes found. Since his time there have been several dozen reports dealing with the histological changes occm-ring in the acute cases, the most important of which are those of Harbitz and Scheel (1907), who reported the changes on 13 cases, Wickman (1905 and 1910), who studied 14 cases, Strauss (1910) who studied S cases and the splendid study of Peabody, Draper and Dochez in 1912. In 1884 the first accurate account of the cerebral type of the disease was given by Striimpell. (See Cerebral Type.) The first 1 Gaz. M6.d., 1866. = Arch, de Physiol., 1870, p. 130. 3 Ibid., p. 310. ■• Ibid., p. 316. 6 Gaz. Med., 1871, p. 457. « Virchows Arch., Ixviii, 109. ' Pepper's System of Medicine, v, 1113. * Zur Kenntniss der Veriindeningen des ncrven Systems bei Poliomyelitis Anterior acuta, Nord. med. Ark., 1888. 28 HISTORY OF POLIOMYELITIS adult case was described by Vogt^ in 1859. Moritz Meyer, in 1868, reported 2 cases in grown people, and in 1872 Duchenne reported quite a series, and subsequently Bernhardt, Charcot, Kussmaul, Erb, Hammond, Schultze and others, studied adult cases. These were quoted by Seguin.^ Various special phases of the disease were studied, such as the reaction to galvanic electricity by Erb, and to faradic electricity by Duchenne, of Boulogne, but up to Medin's study^ of the Stock- holm epidemic of 1887 the nature of the disease was not understood, although Striimpell and Pierre Marie had recognized that it was an infection, as evidenced by the symptoms and course of the cases in the early stage of the disease.- To Medin, however, belongs the credit of placing the disease definitely in the class of those which occur as epidemics. This he first did before the Medical Congress of 1890. Epidemics of the disease had been recognized before, but the infectious character was apparently not even suspected. Medin gives credit for recognizing an epidemic as early as 1881 to Bergen- holz, who noted 13 cases occurring in the department of Norrbotten. Cordier^ also described 13 cases occurring in the environs of Lyons. Leegaard, in September, 1886, described 9 cases in and about Mandel in Norway, while in America, MacPhaiP and Caverly^ reported the first extensive American epidemic, occurring in Ver- mont. Following Medin the ill-fated Ivan Wickman, his student and assistant, studied the Norwegian epidemic of 1905 and pub- lished one of the most striking monographs on the subject that has yet appeared. His monograph includes a very thorough study of the epidemiology of the disease, and he deserves special credit for recognizing and describing the so-called abortive or non-paralytic cases. For a number of years no special additions were made to our knowledge of the disease. Lumbar puncture was done in a case of Landry's type on the thirteenth day by Schultze, and he described a diplococcus; and since that time numerous authors have described bacteria of one kind or another. The earliest inocu- lation experiments were those of Biilow, Hanson and Harbitz in 1899. Their observations were made on rabbits, and were not successful. * Ueber die Essentielle Lahmungen der Kinder, Berne, 1859; Schwietzer Monats- schrift f. prakt. Med., 1857-8-9. 2 Monograph, 1874. 3 Arch, des Medecine des Enfants, May-June, 1898, pp. 257-320. ^ Lyons Med., 1888, Ivi, 548. 5 Med. News, Philadelphia, 1894, p. 619. « Med. Record, 1894, xlvi, 673. MEDICAL NOTES 29 The disease was produced in monkeys for the first time })y Land- steiner and Popper^ and ahnost at the same time by Flexner and Lewis,^ and by Strauss^ in America. In 1909 three different observ- ers, working independently, succeeded in transmitting the disease from one monkey to another. These were Flexner and I^ewis in New York, Leiner and von Wiesner* in Vienna, and Landsteiner and Levadidti"^ in Paris. In the same year Flexner and Lewis and Landsteiner and Levaditi also discovered the fact that the virus was filtrable, and this was quickly followed by the observation of Flexner and Lewis^ that recovery from an attack of experimental poliomyelitis afforded protection to a second inoculation. Subse- quently, neutralizing or immunizing substances were discovered in the blood serum of monkeys that had recovered from the disease, as produced experimentally, and this was followed by finding them in the blood serum of human beings who had had the disease by Levaditi and Landsteiner,^ Romer and Joseph,^ Flexner and Lewis,^ Anderson and Frost.^^ The next step in the understanding of the disease came when Flexner and Lewis, in 1910, were able to obtain some rather definite results in monkeys in attempting to prevent the development of the disease through the administration of blood serum either from recovered monkeys or from recovered human beings. They found that monkeys that had been injected with the virus could, in some cases, be saved, while in others the onset was delayed by the intraspinal injections of the immune serum. This method was very soon used by Netter and his co-workers," and they established the fact that injections of immune serum could be made in man in poliomyelitis with safety. The most probable organism was described by Flexner and Noguchi in 1913. Various other points of recent historical interest will be found scattered throughout the text. 1 Ztschr. f. Immunitatsforsch., original, 1909, ii, 377. 2 Jour. Am. Med. Assn., 1909, liii, 1639. 3 New York Med. Jour., 1910, xci, 64. * Wien. klin. Wchnschr., 1909, xxii, 1698. 6 Compt. rend. Soc. de biol., 1909, Ixvii, 592. ^ Jour. Am. Med. Assn., 1916, liv, 45. ' Compt. rend. Soc. de biol., 1910, Ixviii, 311. 8 Miinchen. med. Wchnschr., 1910, Ivii, 968. ' Jour. Am. Med. Assn., 1910, Hv, 178. '» Jour. Am. Med. Assn., 1911, Ivi, 663. 11 Netter, Gendron and Touraine: Compt. rend. Soc. de biol., 1911, Ixx, 625. Netter: Bull, de I'Acad. de med., 1915, Ixxiv, ser. 3, 403. Netter and Salanier: Bull, et mem. Soc. med. Hop. de Paris, 1916, xl, s6r. 3, 299. CHAPTER II. A CONCEPTION OF THE DISEASE. In order to understand poliomyelitis, one should remember that it is a disease due to a filtrable virus, the portal of entry of which has not definitely been determined in cases occurring under natural conditions, but the virus has been found in the nasopharynx, and the disease may be transmitted by rubbing the virus into scarified or normal mucous membrane of the nasopharynx. It may be pro- duced by injecting the virus directly into the nervous system, and in the cases in which infection has been produced by rubbing the virus into the nasopharynx, it is possible that the virus may get into the nervous system directly through the nerves passing through the ethmoid into the brain or through lymph channels, or it may circulate in the blood and reach the nervous system through the choroid plexus. Amoss and Flexner^ have shown that if the virus is injected directly into the blood stream there is a tendency for the virus to be withdrawn from the circulation into the bone marrow and spleen in spite of the apparent affinity that the virus seems to have for nervous tissue. If, however, very large quantities are given the virus may get into the nervous system from the blood stream, or if ordinary amounts are used and a sterile meningitis set up by the injection of horse serum, the virus probably gets into the nervous system through the injured choroid plexus. The disease in the human being is to be regarded as a general infection, in which, probabh^, most of the cases have slight general sjinptoms and may escape diagnosis. These cases are sometimes called abortive or non- parahi;ic. (See same.) In certain other cases the child is taken ill, and after one or two or three days gets better, sometimes almost well, and then is again taken ill with the production of paraly- sis. This group Draper^ has cafied the dromedary group, on account of the sjTiiptoms coming on in two successive humps, as it were. In the non-paralytic cases the virus probably never gets into the nervous system, or if so, is neutralized before it produces any seri- 1 Jour. Exper. Med., 1914, p. 249. 2 Jour. Am. Med. Assn., April 21, 1917, p. 1154. A CONCEPTION OF THE DISEASE 31 oils damage. In the dromedary group the virus in the blood pro- duces the s^inptoms of a general infection and then it gains entrance to the nervous tissue with the production of paralyses and other nervous s.Mnptoms. In another group of cases the child is ill for two or three or more days and there is no remission in the illness, and these are doubt- less cases in which the original dose of the virus is either greater or more intense, or else the individual's resistance is lower, and the symptoms of a general infection keep up until the nervous symptoms are manifest. And, lastly, there is a group in which the nervous sjTnptoms may be marked from the first, and these may doubtless be due to either the virus reaching the nervous system immediately on its entrance to the body or to the original infection producing very slight general symptoms for some reason or other. CHAPTER III. PATHOLOGY. As far as we have seen the portal of entry of the virus into the body is not definitely known, but it seems highly probable that it is in the nasopharynx, from whence the virus either travels along the nerves to the meninges or, what seems more probable, that it invades the lymphatic system and is carried in that way to the various parts of the body. The earlier observers, having in mind the de^'astating effects upon the nervous system, devoted most of their time to the study of the changes in the cord and brain, but Rissler (in 1888), Medin (in 1890), Harbitz and Scheel, Strauss, Wickman and others observed and described the changes in the other tissues of the body, although they did not attach .very much importance to them. The earlier studies were also made upon old cases and the lesions described by them of the scarring that occurs in the cord as noted below. The disease, in place of being a local infection, is to be regarded as a general infection. As in the case of most infectious diseases the virus of poliomyelitis shows a distinct tendency to localize in certain tissues, generally the nervous system and the lymphoid system. Changes are observed in the other organs, particularly in the fatal cases. In dealing with a general infection with a localizing tendency one has to consider not only the fact that it affects cer- tain tissues but that it affects them in different cases to various degrees. In poliomyelitis, in some of the cases, the changes are doubtless very transient, which explains the abortive cases and those with a transient paralysis. In others the lesions are of mod- erate seA'erity, with a distinct tendency to clear up so that the ultimate paralysis is trifling compared to that which is seen at first. In still other cases the amount of damage done is extensive and beyond repair, while in many the destruction may be so wide- spread or affect such centers as to cause death. The cerebrospinal fluid is usually somewhat increased and shows certain changes described in the section on that subject. The earliest changes consist of a congestion affecting the bloodvessels PATHOLOGY OF POLIOMYELITIS 33 supplying the meninges, the brain, and spinal cord, and this shows a tendency to be asymmetrical. Along with this congestion there is an exudate of small round cells, probably lymphocytes, which ant a. spin, post spin, post. Fig. 5. — Dots show chief areas of disease in acute poliomyelitis. Fig. 6. — Acute poliomyelitis. Photograph showing the swollen ghost-like ceils of Clarke's column and the surrounding cellular infiltration of the tissues. 34 PATHOLOGY OF POLIOMYELITIS crowd the perivascular hTaph spaces of the leptomeninges, but there is no exudate to amount to anything and no deposits of fibrin. The changes are most marked in the places in which the cord is most vascular — that is, in the cervical and lumbar regions, and particularly the anterior part of the cord and the anterior fissure in which run the vessels supplying the anterior part of the cord. There are, however, changes throughout the cord and also in the posterior region. The exudate of small round cells and the hyper- FiG. 7. — Acute poliomj'elitis. An anterior cornual cell in fair preservation, although surrounded on all sides by inflammatorj^ cells. emia around the bloodvessels of the cord may be so great as to cause an obstruction of the circulation at certain points. With this there is a more or less marked edema. Throughout both the gray and white nervous tissue may be seen small punctate hemorrhages, occasionally even larger ones. The exudate, the hemorrhages, and the edema and the toxic action of the virus produce changes in the nerve cells. It is impossible to state how much of the change is due to the toxic action and how much is due to the mechanical changes — that is the anemia which follows the pressure upon cer- tain vessels. The lesions are always worse in certain areas and shade off' into the surrounding portions of the cord, which explains the fact that the initial paralysis is almost always of a very much greater extent than that which becomes permanent, as a large PATHOLOGY OF POLIOMYELITIS 35 number of nerve cells are temporarily interfered with, and as the exudate is absorbed the edema disappears and the congestion grows less; these cells recover entirely, whereas the cells which are in the part most affected may be permanently damaged, and these may be seen in all stages of destruction and degeneration, from those which show only very slight changes to those which have become necrotic and granular. In these latter areas the polymorphonuclear neutrophils invade the nerve cells by their phagocytic action, remove the necrotic tissue, and so pave the way for the late changes which take place. S&^5^ Fig. S. — Acute poliomj-elitis. This photograph illustrates the fact that the vessels of the posterior arterial system are involved, as well as the branches of the anterior spinal artery. This vessel lies in the posterior median fissure. In the brain, pons, and medulla similar changes may be noted. Lesions follow the distribution of the blood supply, but are usually not sufficiently extensive to produce motor changes. In some instances the changes may be limited to the upper neuron tracts, and such cases were first described by Striimpell in 18S5. These cases are considered more at length in the section dealing with the clinical history of the disease. In many instances the clinical symp- toms and the changes noted at autopsy do not coincide, but these discrepancies will probably be cleared up by further histological studies. In the posterior nerve roots the lesions are of almost constant 36 PATHOLOGY OF POLIOMYELITIS occurrence and the changes are like those which take place in that cord. An infiltration of small mononuclear cells in the space sur- rounding the bloodvessels supplying the ganglia and the degenera- tion and necrosis of the nerve cells may occur in the early cases, and the phagocytic action of the leukocytes is also present and dis- poses of the necrotic material as explained before. There is also infiltration of the cells along the nerve roots. Involvement of the sensory ganglia may explain the pain so common in the acute cases. The changes in the old cases consist of an atrophy of the cord, which is most often limited to one lateral half of the cord; but in Fig. 9. — Acute poliomyelitis. Dense cellular exudation and proliferation in the ante- rior gray matter of the lumbar cord. All the ganglion cells have disappeared. this, of course, there is a great variation according to the amount of original destruction. The changes are of a sclerotic character and the scarring of the cord on section is very apparent. The lesions are often only in one anterior horn. The ganglion cells are either wanting entirely or diminished in numbers or else so degen- erated that they can scarcely be recognized. The fibers of the anterior horn are also degenerated and the nerve trunks are atro- phied and degenerative changes have taken place. The white matter of the cord is aflfected to a very much less extent. There is degeneration and atrophy of the anterior nerve roots and of the PATHOLOGY OF POLIOMYELITIS 37 nerves and muscles themselves. The muscle fibers are often degen- erated as well as atr()i)hied, and in many cases replaced by fibrous Fig. 10. — Acute poliomyelitis. Anterior edge of cord in lumbar region. An anterior root bundle is seen passing through the soft meninges, which are infiltrated with round cells. Fig. 11. — Acute poliomyelitis. From a case which died on the fourth day of illness. Twelfth dorsal segment. Note the swollen and prominent aspect of the gray matter and the dark outlines of the radial vessels in the white columns, due to intense perivascular round-cell infiltration. tissue. The afl'ected extremities grow more slowly, and after two years from the onset the patient can be said to be in the final or 38 PATHOLOGY OF POLIOMYELITIS atrophic stage. The bones are smaller and show atrophy, which is apparent to casual examination, and it has also been demonstrated at autopsy and by .r-ray examinations. As the child grows there are often deformities of the bones and shortening of the entire Fig. 12. — Pciliomyelitis. High power, showing complete absence of cells in the horn; bloodvessels and scar tissue remaining and liquefaction of the tissue. The child's thigh and leg were atrophic and totally paralyzed. (Larkin.) extremity, due to pulling of muscles that remain paralyzed. This condition is described somewhat more fully under the symptoma- tology of the late cases. The changes in the other organs have been noted by numerous observers, among them Rissler,^ Harbitz and Scheel, Medin, Wick- 1 Zur Kenntniss der Veranderungen des nerven Systems bei Poliomyelitis Anterior acuta, Nord Med. Arch., 1888, xx, 1. PATHOLOGY OF POLIOMYELITIS 39 man and Strauss. These changes are of very constant appear- ance. Next to the nervous tissue the virus seems to have a distinct tendency to involve the lymphoid tissue and, perhaps, to a lesser extent, the parenchymatous organs. The most striking changes in the lymphoid tissue are met with in Peyer's patches of the intestine and the mesenteric lymph nodes. Sometimes the lymph nodes in other parts of the body may be enlarged, such as the axillary, cer- vical, and inguinal, and also the substernal and bronchial nodes; the lymph tissues on the throat are also affected, the tonsils and adenoids and other lymph structures. The thymus is also involved. Some of the enlarged lymph nodes are more or less normal on his- tological study, but usually they show the invasion of a zone of lymphocytes about pale centers that are made up largely of endo- thelial cells. The spleen may be slightly enlarged, and on section the Malpighian corpuscles are prominent. The changes in these organs as well as those of the other parenchymatous organs suggest those met with in other infectious diseases. In the liver cell necroses of varying extent are met with, sometimes only one or two cells being involved, other times a considerable portion of a lobule being affected. CHAPTER IV. THE NATURE OF THE VIRUS. The virus can be filtered through a Berkefeld filter, which places the disease among those ordinarily classed as being caused by a filterable virus. The virus withstands exposure to light, heat, cold, and drying rather more than do the ordinary bacteria. It will retain its virulence in the height of the summer heat even when dried on pieces of clothing, and it is not destroyed by the action of ordinary weak chemicals. It withstands glycerination a long time, and is not injured by 0.5 per cent, phenol. It may be frozen at —2° C. to —4° C. for four days without materially affecting it. It is destroyed by heating one-half hour at from 45° to 50° C. It is also destroyed by exposure to sunlight and by the action of 2 per cent, hydrogen peroxide, by menthol solutions, mercuric bichloride, iodin, and, in fact, by any of the stronger disinfectants. Ordinary solutions used in the nose and throat as preventives do not prevent the development of the disease. The virus obtained from the human body is not particularly infective for monkeys, and it has to be used in amounts and under conditions that may be regarded as artificial. There are great variations in the strength of the virus, both as it occurs in human beings and in monkeys. In the human being it is probably most infective during the first week or two of the disease, and probably in mcst instances begins to be attenuated after that time, although it may persist apparently in its full strength over long periods of time. In the monkey the virus tends to become fixed, very much in the same manner that the rabies virus becomes fixed in the rabbit. There are, however, some samples of the virus that cannot be intensified or fixed. When fixed it becomes strongly virulent, so that only very minute quantities are necessary to infect a second animal. This intensity of the fixed virus remains constant through a long series of animals, but eventually, as has been shown by Flexner, it loses some of its infective power, and in this way resembles the variations seen in difi'erent epidemics of the disease in human beings. There are periods in which the disease is epidemic VIRUS IN THE HUMAN BODY 41 in which the virus seems to be partieuhirly ^'i^ule^t, and after a certain time the virulence seems to change. Just what brings about this change is not at all understood at the present time, but this variation in virulence probably has something to do with the recurrence of epidemics. Further studies are needed to determine the presence of the relative virulence of the virus as it is found on fomites. The few observations made have merely demonstrated that the virus may be found on objects that have been in intimate contact with patients suffering with the disease. Just how long the virus may be dried under natural conditions before it loses its virulence is at present a matter of question. Romer, Flexner and Lewis, Landsteiner and Levaditi think that this period is several days, whereas Wiener and von Wiesner believe that if the material is allowed to dry slowly, in a thin layer, it will become non-virulent in twenty-four hours. The more we see of infectious diseases in general the less impor- tance we attach to transmission by fomites as a means of spreading disease, and we think this opinion will be borne out by all who have had much practical experience with them. Many studies have been made on the virus under artificial con- ditions: for example, Landsteiner and Levaditi, and Pastia^ found that the virus lived at ordinary room temperature and light when kept in sterile milk or water. Flexner and Amoss^ have kept specimens of virus of poliomyelitis in the spinal cord and medulla of human beings and monkeys in 50 per cent, glycerol at refrigerator temperature for six years. The specimens had lost a part of their activity and it took larger and repeated doses to produce infection. The tissues employed did not show any streptococci or other ordinary bacteria. The Virus in the Human Body. — At autopsy the virus may be demonstrated in the tissues and secretions by inoculated emulsions of these into monkeys. The changes produced in the monkeys are characteristic and the virus may be further transmitted to other monkeys through large series of animals covering long periods of time. The chief locations of the virus in the body are the central nervous system, the brain, spinal cord, and the nerves, and it is also found in the lymphatic system, chiefly in the mesenteric nodes. It is also found in the tonsils and in the nasopharyngeal mucous membrane. It is found less frequently in other tissues, and only 1 Ann. de I'lnst. Pasteur, 1911, p. 805. 2 Jour. Exper. Med., April 1, 1917, p. 539. 42 THE NATURE OF THE VIRUS exceptionally in the blood. In the living body, in those acutely ill with the disease, it is found in the nasopharyngeal secretions and in the washings from the rectum. It has been demonstrated in this way in the typical cases and also in the indefinite and abortive forms. Kling, Wernstedt, and Pettersson and others have demon- strated it in the mucous membrane of the nasopharynx and rectum in convalescent patients, and it may persist for weeks or even months. Persons associated with cases of the disease, especially in times of epidemics, may also have the virus in the nasopharynx or intestinal tract without ever having had any symptoms of the disease. Curiously enough the virus has apparently never been demon- strated in the cerebrospinal fluid of human beings. Flexner and Lewis^ found the virus in the spinal fluid of a monkey three days after the intracerebral injection of the virus. Abramson^ reports that during the New York epidemic of 1916 cultures were made from over 1200 fluids from patients with acute poliomyelitis in all stages of the disease. Except for a few evident contaminations the cultures remained sterile. Observations on animals with the fluids from 40 patients also gave negative results. Nuzum and Herzog^ report that they found a Gram-positive coccus in 90 per cent, of the fluids in cases of poliomyelitis. Further comment is made on their study below. The Choroid Plexus and the Virus. — ^Flexner and Amoss^ haxe shown that the meningeal choroid plexus is normally capable of excluding from the nervous system the virus circulating in the blood and also in preventing infection from the virus present on the nasal mucosa. They have found that normal monkey or horse serum, isotonic salt solution, Ringer's solution, and Locke's solu- tion, when injected into the meninges, cause an irritation which diminishes the protection of the choroid plexus and permits the virus of poliomyelitis introduced into the blood to pass into the central nervous system. Simple lumbar puncture, where there has been no hemorrhage, does not seem to have any influence upon the passage of the virus into the central nervous system; but if there has been hemorrhage, this seems to increase the permeability. Immune serum is the only substance which is not succeeded by infection from the virus introduced into the. blood. These observa- 1 Jour. Am. Med. Assn., April 2, 1910, p. 1140. ^ ibid., February 17, 1917, 3 Ibid., October 21, 1916, p. 1205; Ibid., November 11, 1916, p. 1437. ^ Jour. Exper. Med., April 1, 1917, p. 525. NEUTRALIZATION OF VIRUS BY NASAL WASHINGS 43 tions would seem to be another reason for using immune serum in preference to any of the other substances suggested. The Virus Outside the Body. — Numerous studies have been made on this subject, and it has been demonstrated by Neustaedter and Thro^ in the dust of rooms that had been occupied by three different eases. It has also been demonstrated on handkerchiefs and embroid- ery work that have been about the patient, but comparatively few observations have been made upon this subject. The virus has also been studied outside the human body under artificial conditions. The Length of Time the Virus Persists.^ — In the bodies of monkeys the virus is found to disappear from the central nervous system in from three to six weeks, but it remains in the mucous membrane of the nose and throat and apparently also in the intestine. In man the virus apparently grows rapidly weaker after the first eight to fourteen days, and in most instances has disappeared com- pletely, or almost so, after a period of three or four weeks; but it may persist much longer, and has been demonstrated in the secre- tions of the mouth for six months after the onset of the disease. For ordinary purposes of isolation from six to eight weeks have been advised, but this will permit a certain number of individuals to go about with a more or less attenuated virus still present. From practical observations in the New York epidemic two weeks would seem to us to be a suitable isolation period. Neutralization of the Virus of Poliomyelitis by Nasal Washings. — Amoss and Taylor^ have made some interesting experiments and have shown that the washings of the nasal and pharyngeal mucosa possesses a definite power to inactivate or neutralize the active virus of poliomyelitis. This power varies at different times in the same individual, and inflammatory conditions of the nose and throat either diminish or inhibit the power of neutralization entirely. The neutralizing substance is water-soluble and apparently is organic. Its action apparently does not depend upon the presence of mucin as such. They have not made a sufficient number of tests to ascertain whether adults and children differ with respect to the existence of this neutralizing property in the nasal secretions. They suggest that it is possible that the production of healthy car- riers through contamination with the virus may be determined by the presence or absence of this inactivating or neutralizing property in the secretions. This subject may prove to be a fertile field for 1 New York Med. Jour., September 23, 1916, p. 613; October 21, 1911, p. 813. 2 Jour. Exper. Med., April 1, 1917, p. 507. 44 THE NATURE OF THE VIRUS further investigation, and it would be exceedingly interesting to have determined what effect antiseptics have on these substances. The Cultivation of the Microorganism Causing Poliomyelitis. — Noguchi/ working with Flexner in the Rockefeller Institute, has succeeded in growing microorganisms by the use of Noguchi's method for cultivating spirochetes, the material used being nerve tissue derived both from human poliomyelitis and also from experi- mental poliomyelitis in monkeys. The first thing is to obtain the nervous tissue in as early an aseptic condition as possible, and for this purpose the brain is to be preferred, because it is more easily separated from the rest of the body in a more suitable condition than the other portions of the nervous condition. Pieces of about 2 c.c. thickness are taken, and inoculations are made both with fragments and, if there is any reason to suspect contamination, with filtrates. The filtrates are made by grinding the nervous tissue with sand in distilled water or normal salt solution. This emulsion is then shaken in a machine for about thirty minutes, centrifugalized, and the supernatant fluid through an N or V Berkefeld filter. The culture medium used is made of human ascitic fluid to which has been added a fragment of sterile, fresh tissue. For the initial cultures it is necessary to exclude oxygen by cov- ering the liquid with a deep layer of sterile paraffin oil. It is not essential that the tubes be placed in an anaerobic jar, but it would seem that the initial growth is more easily obtained when this is done. The tubes for the cultures measure 1.5 by 20 c.c, and in ea3h oi these is pla3»d a fragment of sterile rabbit kidney and a fragment of an equal size of nervous tissue. Upon these are poured about 15 c.c. of sterile ascitic fluid, and, finally, about 4 c.c. of sterile paraffin oil. The ascitic fluid must be originally sterile, as sterilization either by fractional heating or filtration renders it unsuitable. The experiment is controUed by other tubes contain- ing kidney and ascitic fluid and brain and ascitic fluid; two sets should be prepared, one of which is to be placed in an anaerobic jar and the other kept outside, but both are to be cultivated at the ordinary thermostat temperature, namely, 37° C. The tubes in the jars are not disturbed for from seven to twelve days. Those outside may be inspected daily. If within one or two days there is turbidity, coagulation, or gas-production the tubes may be dis- carded as being grossly contaminated. Small quantities of the 1 Jour. Am. Med. Assn., Ix, 362; Jour. Exper. Med., October 1, 1913, p. 462. MICROORGANISM CAUSING POLIOMYELITIS 45 medium are removed with pipettes and stained for bacteria in the ordinary way and cultivated upon the usual solid or fluid media. If the clear tubes show organisms, they may also be discarded. In the other tubes, at the expiration of about five days, there is an opalescence about the organisms at the bottom of the tube. This may be gradually diffused throughout the tube by gentle shaking. The control tubes, when not contaminated, either remain perfectly clear or have a slight granular precipitate of washed-out granules of tissue about them. In from three to five days the opalescence extends into the upper portions of the medium, while, in the control tubes, the precipitate gathers more and more at the lower end of the tubes. After ten to twelve days the diffuse opalescence dimin- ishes and small particles of it begin to fall slowly to the bottom of the tube. The tubes in the anaerobic jar on the seventh day show a similar growi:h, but somewhat less marked. At the end of five or six days the appearance is very much that of the tubes that have been kept in the air for one week. The organism may also be cul- tivated on a solid medium consisting of ascitic fluid and sterile rabbit tissue to which a suitable culture of 2 per cent, nutrient agar has been added in order to produce a solid mixture. This is not suitable for the initial growth, but once the culture has been secured in the fluid medium it is possible sometimes, but not always, to transmit it to the solid medium. It is possible to secure cultivation even in the absence of the rabbit tissue, and for this purpose a somewhat larger fragment of nerve tissue is used. The experiment is less apt to succeed, however, than when the rabbit tissue is used. Other fluid culture media have also been used, consisting of sheep serum water or an extract prepared from the brain tissue, but neither of these are suitable without the addition of rabbit tissue, and they are not as useful in studying the organism. Glycerinated fragments of nervous tissue kept in 50 per cent, glycerin, at a temperature of from 2° to 4° C. for periods varying from twenty- five days to one year, were also used, and the resulting growths, when they occurred, produced the characteristic appearances already noted. In 33 experiments an initial growth was obtained in 19 instances, 16 of which proved to be pure and 3 were mLxed with other organisms. Of these, pure subcultures were obtained 13 times, and in many of these the subcultures were maintained alive for an indefinite period. The fluid cultures, under the dark-field microscope, show globular bodies of very small size which hang together in small chains, parts, or in small masses. They are devoid 46 THE NATURE OF THE VIRUS of the independent motility and difficult to separate from the numer- ous small, moving granules which are always present. The stain preparations bring these small bodies out plainly. The organisms may be stained either by the method of Giemsa or by Gram's method, but in either case the staining is accomplished with more or less difficulty. From the fact that the microorganism described was so con- stantly found in the central nervous system of both human beings and monkeys infected with poliomyelitis it was strongly presump- tive that it bore a very close relation to the disease. Two series of inoculations were made into Macacus rhesus monkeys, one being from cultures derived from human beings and the other from monkeys. The cultures were inoculated into the brain or into the sciatic nerve or peritoneal cavity simultaneously. It was possible to produce in monkeys typical poliomyelitis which showed typical lesions at autopsies, and from which, in some instances, the cul- tures could again be recovered. The microorganism can be detected in film preparations and in sections prepared from the central nervous system of human beings who had died of poliomyelitis, and from monkeys in which the disease had been produced experi- mentally. It will not be necessary to go into the technic which was devised by Noguchi for demonstrating these, the details of which are given in the articles from which these extracts have been made. These microorganisms are very small, measuring from 0.15 to 0.3 micron in diameter. They are grown under conditions which are favorable to the growth of bacteria, but the observers at present have no opinion to offer as to the place which these organisms occupy among living things. Whether the organism is a bacterium or a protozoan has not been determined. What is known is that it passes through a Berkefeld filter, that it is capable of recultivation, apparently indefinitely, and that the organism is identical whether derived from human sources or monkeys. Great difficulties are experienced in obtaining the initial culture, and it is not always possible to demonstrate the organism; even when the organism is grown it may not possess a sufficient degree of patho- genicity to cause an infection in the monkey. It is possible that there are two factors present in the culture — one invisible and the other the globular bodies described. As far as we know this work has not been very largely confirmed by other observers, but, on the other hand, there has been nothing done to contradict it unless it is the work mentioned below. INVESTIGATIONS OF THE CULTIVATION OF THE VIRUS 47 The Bacteriology of Poliomyelitis. — The earlier investigations on the bacteriology of poHomyehtis were largely limited to the finding of diplococci or micrococci in the cerebrospinal fluid. Biilow- Hansen and Ilarbitz^ isolated a diplococcus from acute cases, and Harbitz and ScheeP confirm their observations. Geirsvold^ found a diplococcus in 12 cases and claims to have caused paralysis and death by inoculation into animals. Pasteur, Foulerton and Mac- cormac* found a micrococcus in the fluid which, when inoculated into rabbits produced a disease condition similar to that seen in human beings. Similar observations were made by Dixon and Fox in the Pennsylvania epidemic of 1907, and they found a diplococcus not only in the cerebrospinal fluid, but also in the nose and throat of patients suffering with acute attacks of the disease, and Rucker^ studied this diplococcus, which would seem to be similar to that described below in the consideration of the recent investigations. Recent Investigations of the Cultivation of the Virus. — Several articles have appeared recently dealing with this subject, the first by Mathers,^ the second by E. C. Rosenow, Towne and Wheeler,^ and the third by Nuzum and Herzog.^ All these articles deal with the cultivation of a micrococcus. Mathers used the material from the brain and cord obtained at autopsy under sterile conditions, and as soon after death as possible, and inocu- lated it into the various mediums, as ascites fluid and ascites- dextrose agar containing a small piece of rabbit kidney, ascites- dextrose broth, and coagulated with normal horse serum. The cultures were made both aerobically and anaerobically, and were incubated at 35° C. for from one to seven days. In 7 of 8 cases, after thirteen hours in aerobic cultures, and in from three to seven days in anaerobic cultures, a Gram-positive micrococcus was obtained, and in 6 of these the organism was in pure culture. Cul- tures from the heart blood and from the cerebrospinal fluid after death did not show the organism, but it was demonstrated in the mesenteric Ijinph nodes. It is of low virulence for rabbits, but when injected into the veins in large doses, lesions of the central nervous system are produced, with paralysis, particularly of the 1 Norsk. Mag. Laegevidensk., 1898, xiii, 1170. 2 Jour. Am. Med. Assn., 1908, 1, 281; ibid., xlix, 1420. 3 Norsk Mag. Laegevidensk., 1905, p. 1280. 4 Arch, for Middlesex Hospital, London, 1908, xii, 208; Lancet, 1908, p. 484. 5 Reports of the Health Department of Pennsylvania, 1907, p. 420. 6 Jour. Am. Med. Assn., September 30, 1916, p. 1019. ' Ibid., October 21, 1916, p. 1202. 8 ibid., p. 1205. 48 THE NATURE OF THE VIRUS extremities. Intracerebral injections into a monkey also caused paralysis. After three or four transfers on artificial mediums, the organism seems to lose its affinity for the nervous system. Rosenow, Towne and Wheeler made a study of the throats, ton- sils, spinal fluid, blood, central nervous system and other tissues, and isolated a peculiar polymorphous streptococcus from the throat and tonsils, and from abscesses in the tonsil in a large series of cases of epidemic poliomyelitis. They also obtained it from the ventricular fluid after death and from the blood in one instance, but not from the spinal fluid. Their organism was apparently the same as that of Mathers. The cocci, when grown under anaerobic conditions, has a tendency to become very small, and suggested the globoid bodies described by Flexner and Noguchi, and the smallest of these could be filtered through Berkefeld filters, while the larger ones could not. It is now suggested that the globoid forms described by both authors may be due to the breaking down of some of the larger diplococcus forms. BulP has made a study of streptococci cultivated from the ton- sils of 32 cases of poliomyelitis, and observations were made on guinea-pigs, dogs, cats, rabbits, and monkeys. In no case was anything induced resembling poliomyelitis, either clinically or pathologically, but some of the animals developed lesions ordi- narily seen in streptococcus infection. These lesions did not seem to vary in character or frequency from those caused by streptococci from other sources. The monkeys whi?h had recovered from infection from streptococci from poliomyelitis did not show any protection from infection with the filtered virus, and their blood did not neutralize the filtered virus in vitro. These observations may be taken distinctly against the idea that poliomyelitis is caused by a streptococcus, and it is also a fact that the thousands of cases seen in New York in the summer of 1916, in which there was no instance of metastatic infection and inflammation, such as are ordinarily seen in streptococcus infection. Another recent study has been made by Kolmer, Brown and Freese.2 They found that in cases of acute poliomyelitis that four different kinds of microorganisms could be grown without diffi- culty. These were streptococci, diplococci, diphtheroid bacilli, and Gram-negative bacilli. The streptococci were found to be grown 1 Jour. Exper. Med., April 1, 1917, p. 557. ^ ibid., June 1, 1917, p. 789. VIRUS IN MONKEYS 49 both aerobically and anaerobically, and under the latter conditions the organisms l)ecame small and round, and they were more easily decolorized with alcohol in the Gram stain than the others. 1'hese organisms were not found in the cerebrospinal fluid in 10() different observations, but they were found in one of 20 anerobic blood cultures, and in fatal cases were easily isolated from the nervous tissue, tonsils, liver, lungs, kidneys, spleen, pancreas, thymus gland, suprarenal glands, and mesenteric lymph nodes. The diplococci were Gram-positive, and when trans- planted to solid media grew abundantly and looked like a staphy- lococcus that grew both aerobically and anaerobically, and under the latter conditions the growth was slow and the cocci became small and round. They found these organisms in 48 out of lOG cerebrospinal fluids, and also in the nervous tissue and organs mentioned above. These organisms did not produce any paralytic conditions either in rabbits or in monkeys, but the streptococci set up arthritis and meningitis. These organisms are apparently sec- ondary to the real cause of poliomyelitis, or else are terminal infec- tions. Perhaps the chief reason for doubting that the streptococci are the cause of poliomyelitis is that where they have produced lesions in the nervous system they have done so in animals that have ordinarily been found refractory to the virus of poliomyelitis obtained by ordinary methods. It is well known that almost any organism injected into an animal will find its way into the nervous system and cause lesions, providing the animal is not killed too promptly by the germ and the amount injected is sufficient. Until we have evidence of a much more convincing nature than that given up to date, we believe it is pretty safe to state that these organisms are not the causal agent of the disease. The Transmission to Animals. — The only animal that may be satisfactorily inoculated at the present time is the monkey, although rabbits under certain conditions, as given below, seem to be subject to the disease, and possibly, exceptionally, guinea-pigs. Up to the present time it has not been possible to produce the disease in any of the other animals that have been used for observations, including dogs, cats, horses, goats, sheep, and some of the other familiar small animals. The Virus in Monkeys. — The disease may be transmitted by inject- ing the virus into the brain, subdural spaces, or the nerves, into the peritoneal cavity, and less easily by injecting it subcutaneously, and much less so by injecting it into the general circulation. It 4 50 THE NATURE OF THE VIRUS may also be transferred by rubbing it into the scarified or healthy pharyngeal mucous membrane. It may also be transmitted by way of the stomach or intestines, but only by using massive doses of the virus. The virus for experimental purposes usually consisted of emulsions of the various tissues mentioned, either used as such or after filtration through a Berkefeld filter. The disease in the monkey is typical, though not quite identical, with that seen in human beings. The experimental work done upon monkeys seems to point to the fact that the disease may be transmitted under natural conditions through the nasopharynx or through the digestive tract. This question of transmission will be considered under the subheading. Virus in the Guinea-pig. — Whether or not guinea-pigs are suscep- tible to the disease is a matter of some question. Romer and Joseph were unable to transfer the virus from monkeys to guinea-pigs, but they observed that guinea-pigs kept in the laboratory occa- sionally died from a paralytic disease, and Romer, studying this, found that it was apparently due to a filtrable virus. More recently Neustaedter^ claims to have transferred the virus from a guinea- pig to another guinea-pig and back again to a monkey, the guinea- pig having presumably been infected in the first instance through contact with a monkey with the disease. Rosenau and Havens inoculated a few guinea-pigs, and those that died showed lesions somewhat like the ones described in rabbits. They do not consider that their observations are sufficiently advanced at this time to draw conclusions. The Virus in Rabbits. — There have been various statements made concerning the susceptibility of rabbits to the virus of this disease. Krause and Meinicke,^ in 1909, were the first to pass the virus obtained from a human being through seven generations in rabbits, and the following year Lents and Huntemiiller'' were able to pro- duce the disease by using the virus from one rabbit to another by several methods of inoculation, but the lesions in the brain and spinal cord were not as marked as those found in monkeys. Vari- ous other observers, as Romer and Joseph,^ Landsteiner and Leva- diti,^ Leiner and von Wiesner,^ and Flexner and Lewis^ were all 1 Jour. Am. Med. Assn., 1913, Ix, 982. 2 Deutsch. med. Wchnschr., 1909, xxxv, 1825. 2 Ztschr. f. Hyg. u. Infectionkrankh., 1910, Ixvi, 481. 4 Munchen. med. Wchnschr., 1910, Ivii, 2685. 5 Compt. rend. soc. de biol., 1909, Ixvii, 787. fiWien. klin. Wchnschr,, 1909, xjcii, 1698. ' Jour. Exper. Med., 1910, xii, 227. VIRUS IN INSECTS 51 unable to transfer the disease to rabbits. Marks/ using virus from a monkey, passed the (Hsease throu- 4- _c:_ -"- _■*_ — _«:_ ::^ ~ ^° -j- " — =P^ ~ t zzz zz: zz:z E t xn xL JJ Fig. 17. — Chart showing graphically age incidence of 1076 cases of poliomyelitis recorded in 1910. (Department of Health of Pennsj-lvania.) The adults are affected generally to the extent of about 10 per cent, of the various epidemics, but in this there are great variations, at times the percentage being higher and sometimes very much 1 Studies in Clinical Medicine, No. 1, i, 11. AGE 65 lower. Where the epidemic affects a very large number of the population the proportion of adult cases seems to be high anrl a remarkable instance is reported by Miiller^ of an epidemic on the island of Nauru, where, in a population slightly over 25,000, some RATE 1 1 1 1 1 1 1 1 M 1 M 1 1 1 1 1 1 M 1 M RATE = = NU MBER OF CASES OCCURRING AT |EACI^ AOE' PERIOD PER 10,000 IN THE POPULATION. R URAL NEVSi YORK 1 — bvE \R s i NEW YORK C IT y 1 J sW ARfl t>HI 1 UPSTATE c TIES I 1 ■ ■ ■ 5, -1 i!o - ■ - ■ ■ ■ ■ ■ 9 ■ I r . ■ ^ ■ ■ in- 5 sSSS 1 _fea| - 1 ■»=» 1 - u 143 77 1 23 1 3 119 1 29 5 0.4 1 44 1 15 1 5 1 0.6 1 140 120 100 60 RATE Fig. 18. — Comparative incidence rates of poliomyelitis, by age periods, in different sections of New York State during the epidemic of 1916. (Courtesy of Dr. Mathias Nicoll, Jr., New York State Board of Health.) 700 cases occurred within a few weeks, the majority of which were in adults. The following table gives some of the figures from some of the reported epidemics : 1 Arch, f. Schiffs u. Trop. Hyg., 1910, xiv, No. 17. 66 EPIDEMIOLOGY By Age Periods. Massachusetts Epidemic of 1910. Per cent. Cases. Approximate. From birth to twelve months, inclusive .... 51 8.5 From thirteen months to twenty-three months, inclu- sive 65 Two years old 61 Three years old 98 Four years old 69 Five years old 51 65 . 5 395 Six to ten years, inclusive 93 80.8 488 Eleven to twenty years, inclusive 69 92.1 557 Twenty-one to thirty years, inclusive 28 Thirty-one to eighty years, inclusive 15 600 Occurrence by Age Periods (1908-10). Age, years. Cases. Per cent. Birth to twelve months inclusive 55 6.13 One year old 119 13.26 Two years old 155 17.35 Three years old 125 13.93 Four j^ears old . 92 10 . 25 Five years old 54 6 . 02 600 Six to ten years, inclusive 145 745 Eleven to twentj^ years, inclusive . . . . . .83 828 92.35 Twenty-one to thirty years, inclusive 39 4.34 Thirty-one to seventy-two years, inclusive .... 17 1.89 Not stated 13 897 Age Incidence in Five-year Periods, Expressed in Percentages. (Erost.)^ New York Commission Lovett, Mass. Hill, Minn. (729 cases; (615 cases; (325 cases: per cent, of per cent, of per cent, of Age. total). total). total). Under one year 8.5 7.2 6.5 One to five years 82.0 64.5 48.6 Eleven to fifteen years ....1.9 5.0 7.7 Sixteen to twenty years ....0.68 2.4 6.5 Over twenty years 0.4 5.0 7.0 > Jour. Am. Med, Assn., June 10, 1910. RELATION OF NOSE AND THROAT TO POLIOMYELITIS 07 Social and Hygienic Conditions. — Curiously enough, in a general way the influence of poverty and unsanitary conditions does not seem to be as important in poliomyelitis as in other diseases. In the New York epidemic of 1916 Emerson cites the fact that Barren Island, in Jamaica Bay, on which all garbage and dead animals frf>m New York City are dumped and which has no public water supply, no sewerage system, no cellars and no garbage collection and on which 1700 people, of which 350 are children, live — the sanitary conditions may well be imagined — there was not a single case of poliomyelitis. The same absence of the disease has been noted on other islands by other observers, showing that the virus must be introduced into a community before the disease starts. Most authors state that rich and poor are affected alike, and taking into consideration the relative numbers of both, this is apparently true. Numerically, the greatest number of cases occur in poor people, but when one takes into account that very much larger proportion of persons with insufficient income, the figures are easily explained. The character of houses does not seem to make any particular difference, the disease occurring with about the same frequency in tenements as in detached houses. This point was carefully studied in the epidemics occurring in Massachusetts. Poliomyelitis in Lower Floors. — A point of extraordinary interest is brought out in the New York epidemic of 1916, in which it was found that most of the cases of the disease occurred on the first and second floors of the taller houses and a very much lesser pro- portion of cases on the floors above. The explanation of the greater number of cases on the lower floors may be due to the fact that they have less light, less air, and are more exposed to rodents than the upper floors. Scarlet fever and diphtheria do not show this tendency to show a larger number of cases in the lower stories. This point may be of importance in solving the problem of transmission, inasmuch as it seems to be a point in the favor of the possibility of the disease being transmitted by rat fleas. The Relation of the Nose and Throat to Poliomyelitis.- — In the New York epidemic of 1916 a study was made to determine if there was any relation to diseases of the nose and throat and poliomyelitis, and whether the disease was more common with adenoids and tonsils than in those in whom they had been removed. It was found that a large number of children with poliomyelitis had pathological conditions of the nose and throat, either disease and hypertrophy of the tonsils and adenoids or both. This, of course, 68 EPIDEMIOLOGY would be expected, as disease of the tonsils and adenoids is extremely common at the present day in early life. It was also noted that a large number of children with poliomyelitis showed marked hyper- emia of the nasopharynx and throat, that is, of the tonsils, anterior pillars, and soft palate. This condition often resembled that seen in scarlet fever, or due to infection with a streptococcus. It was also observed that only a small percentage of cases previously operated on for tonsils and adenoids were found afterward with the disease, and in that group of cases the percentage of recoveries was very much higher than in unoperated cases. The number is too small to draw any very definite conclusions, but at the same time it is very suggestive. A series of 2000 cases was studied. Of these, 45 had been oper- ated upon; 19 out of 39 of these recovered completely, or 46 per cent.; 1955 cases were not operated upon. There were complete recoveries in but 15 per cent. While these observations are strik- ing, one should be slow in jumping at any conclusion, and they should be confirmed by other observers in other localities before being made a basis for practical application. Another study was undertaken on 1404 children whose tonsils and adenoids had been removed. Not one of these developed the disease, although in 18 instances cases developed in the family, and in 93 instances in the same house. Poliomyelitis and Decayed Teeth.^ — Fischer^ suggests the possi- bility of the infection entering through carious teeth. Whether or not this is the case, the mere suggestion is a very strong point in urging the all-important dental hygiene, a much neglected point, particularly in children. Type of Child Most Often Affected. — Draper- has made some interesting observations which we quote verbatim: "The type of child which seems to be most susceptible to the disease is the large, well-grown, plump individual who has certain definite characteristics of face and jaws, is broad-browed and broad and round of face. The teeth are particularly interesting. It was noted that in 50 to 60 per cent, of all the cases in the hospital at Locust Valley the central incisor teeth of the upper jaw were sepa- rated by a cleft of varying width. The wide-spaced dentition has been a striking feature and frequently involves all the single teeth of both jaws, so that each tooth stands entirely free. 1 Weekly Bulletin of the Department of Health of New York, May 12. 1917, p. 146. 2 Acute Poliomyelitis, p. 8. THE NEW YORK EPIDEMIC 09 "Among the adolescents and young adults who acquired polio- myelitis and in whom the disease always seemed to be most severe and, indeed, usually fatal, the type differed from that just described. Instead of the \'ery large, well-nourished individuals with widely spaced teeth, there appeared a more delicately made type. Of the 6 or 8 fatal cases in young adults seen, the similarity of appearance of the individuals was so striking that all might ha^'e been of one family. x\ll were brunettes, with very delicate dark skins and high coloring of cheeks and lips. Often, small, deeply pigmented moles were present on face or neck. In all cases there was present a certain maxillary prognathism and instead of dental separations a tendency to crowding of the teeth." Immunity. — Flexner and Lewis have demonstrated that mon- keys that have had the disease and recovered are immune to further inoculations and individuals who have had an attack are appar- ently immune, but there are some exceptions to this. (See Relapses or Recurrences.) In the New York epidemic of 1916 there were two instances of the disease in children who had had previous attacks. This subject will need further study to determine how long the immunity lasts. It would seem that it would be possible to clear up one of the moot points as to whether a large proportion of the population had had the disease by some time making proper tests of the blood on a large number of individuals selected at ran- dom. This, of course, would be an exceedingly expensive and tedious undertaking, but, at the same time, one that would be perfectly feasible. The New York Epidemic. — In the year 1916 the State of New York experienced the most extensive epidemic of poliomyelitis on record. We are indebted to Dr. Mathias Xicoll, Jr., of the New York State Department of Health, for this account of it : From June to December there were 13,000 cases and 3300 deaths. Of these, 8991, or more than tw^o-thirds, occurred in New York City, 4186 representing the cases in the other part of the State. The epidemic began early in June in the Borough of Brooklyn. First the spread was slow, but later increased in intensity and later invaded practi- cally the entire State. The disease spread along the routes of travel, particularly the suburban lines out of New York City, east into Nassau and Suffolk counties, and northward to the outlying communities in Westchester. The counties bordering on the Hudson River w^ere then invaded and the disease spread north and northwest along the railroad lines out of the State, 70 EPIDEMIOLOGY The fatality rate was about 25 per cent., which is higher than the rate observed in any of the previous large epidemics. The table of the epidemic shows an apparent increase in the fatality rate toward the end, but this was probably due to the fact that the number of cases were rapidly diminishing, while the previously reported cases were dying off; this causes the apparent increase in the rate. ■ " ■■ * ~ ~ ~ — ~ "■ ~ " L~ *>r innn 1000 1 / \ / j f 1 \ / s 800 s L \ 600 \ 1 1 1 !2 \ 1 \ 400 / .^ ' 4 N A ■ ^ / f > / ^* \ 200 > / ' V / ^ . ^ ■s ' -. ^ ^ n , T S — - ' ~" ^ .A^ 600 6 13 20 27 3 10 16 23 30 6 13 20 27 3 10 17 24 1 8 15 22 29 4 11 18 25 2 JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DEC. Fig. 19. — Reported cases of poliomyelitis, week by week, during the epidemic of 1916, in New York City (dates of report) and upstate (dates of onset). (Courtesy of Dr. Mathias Nicoll, Jr., New York State Board of Health.) In the rural districts a much higher proportion of the population was affected than either in New York City or the up-State cities. On an average, 2.4 per cent, of the persons of the rural sections were attacked and only 1.6 in New York City, and 0.6 per thousand in the up-State cities, as a whole. The deaths, however, were less in the rural sections, 19.8 per cent., the up-State cities following with 22.6 deaths per 100 cases, and in New York City, 27.2 per cent. The number of deaths among males was 50 per cent, higher than among females. Practically the same proportion, 60 and 40 per cent, were observed in New York City and up-State, at the different ages and from month to month. In the first 7500 cases in New York City, almost 80 per cent, were among children under five years of age; over 95 per cent, under ten, and over 98 per cent, under sixteen, while in the up-State less than two-thirds of the cases were under five years, 86 per cent. THE NEW YORK EPIDEMIC 71 under ten, and over 7 per cent, beyond the age of fifteen. In rural New York only 55 per cent, of the ca.ses occurred amonfj children under five years of age, half as many between the ages of five and ten, and 10 per cent, of all cases were among persons older than fifteen. The higher fatality among adults shows a decided contrast ~ ■" ■ ■ i I 1 1 R/ TES Pi R 10 oc PO PU J kT o^ IN 1 HE AREAS AFFECTED CASE RATE 37. ) 23.6 ;o.o 6.0 7.0 PER CENT FATAL ja.8 i U.8 27.2 22.6 1 3.1 1 DEATH RATE 1 : 0.1 4.7 4.1 l.t ." 1 -- h-r-r- 1 .', t ; 35 f i h 35 ( I ; ' ; ; ; ; 1 ; ; SURVIVED TOTJAll , } ' ( III 30 ',',''!'' CA^ES \ II ' 30 DIE.D I i ' ' K - 25 ',',''' 20 ' ; ' t ' ; 15 ' ■ ; i ' 15 ' ; , ; ' ; ; ; '',[', ; ' ' ' :'.':■■ ; ; ; ; ■A ; '; ; 1 10 ^, J „,.,,,. ; 1 ,. ,■ ' ■■ ' f ''',', 1 . j I ; •',','• t /r/ / 5 '. \ !••; ' ' ' ' 1 ^^^^^H 1 ^^^^^M 1 ^ I ■ m ■ ■ L _ I ■ ■ ■ ■ L __ I ■ ■ ■ ■ _ 1 ■ ■ ■ ■ L Fig. 20. — Relative severity of poliomyelitis epidemic of 1916 in certain areas, judged by the comparative incidence and death-rates recorded. (Courtesy of Dr. Mathias NicoU, Jr., New York State Board of Health.) in the difTerent sections. In Xew York City nearly 4 out of e\-ery 5 deaths were under five years of age, and 97 per cent, of all deaths occurred among persons under fifteen years of age. In the rural districts 45.5 per cent, were under five years, and 80.9 per cent, under fifteen, with fully 19.1 per cent., or 1 out of every 5 deaths 72 EPIDEMIOLOGY occurring in adults, that is, persons beyond the age of fifteen. It has been suggested that the explanation of the difference is that the urban population has acquired a certain degree of immunity, while the rural population, being more scattered and less in contact, has not. A study made to determine the length of time persons with the disease were a source of active infection show that the period is at least eight days after the onset of the disease, and there was very little evidence of the disease being contracted from a person who had been ill longer than two weeks, which suggests the limit of the necessary period of isolation be required for suspected cases in future epidemics. One of the lessons learned from the epidemic in New York City was the value of publicity and education. The educational cam- paign in New York was thoroughly done through the newspapers, by distribution of literature, and so on, and the result was that an unusual degree of care was taken of all children as regards clean- liness, food, and all other precautions. The result was that there has been a saving of infant life in New York City sufficient to off- set the number of deaths from infantile paralysis. During the first thirty-five weeks of 1916 out of every 1000 infants born 95 died, while during the first thirty-five weeks of 1915 out of every 1000 infants born, 105 died. The infant death-rate is a fair estimate of the sanitary conditions prevailing in a community, and this lowering in New York is attributed to the efi'ect of education which resulted from the poliomyelitis epidemic. CHAPTER VI. THE SYNOX^^MS AND CLASSIFICATION. SYNONYMS. The best term for cases of this disease is poliomyelitis. So many different terms have been used in the past and even at present, for example, in 1909, the Census Bureau had twenty-four terms for the disease, that it would seem to be a wise thing to adopt a uniform terminology. In Europe, where there is a tendency to couple physician's names to diseases, it is often called the Heine-Medin disease. The term poliomyelitis is derived from the Greek words polios, meaning gray, and myelon, meaning marrow. The following list shows the terms that have been or are now used: Dental paralysis (Underwood). Infantile spinal paralysis (Heine). Paralysis during dentition (Gule). Teething paralysis (Marshall Hall). Morning paralysis (\Yest). Essential paralysis of children (Barthez and Rilliet). Regressive paralysis (Barlow). Myelitis of the anterior horns (Seguin). Tephromyelitis (Charcot) from the Greek tephros, meaning ash- gray. Spodomyelitis or spodiomyelitis (^'ulpian) also from the Greek spodios, meaning ash-gray, according to Erb. Acute fatty atrophic paralysis (Duchenne) afterward shortened to atrophic paralysis. ]\Iyogenic paralysis (Bouchut). Idiopathic paralysis. Infantile paralysis. Essential paralysis. Acute spinal paralysis. Acute infantile paralysis. Poliomyelitis anterior acuta. Anterior poliomyelitis. 74 THE SYNONYMS AND CLASSIFICATION THE CLASSIFICATION. The question of classification is a somewhat difficult one, inas- much as the clinical manifestations of the disease do not always correspond to the pathological findings. The lesions are apt to be widespread and scattered throughout the whole nervous system, so that while certain definite types of the disease may be described, there will always be cases which come partly under one group and partly under another. This will be made more clear by considering the classifications that have been suggested. There is no real need for exact classification except that it facilitates the description of the disease and makes the task of learning about it simpler. The first classification of any importance is that of Wickman. He divides the cases into the following forms: 1. The spinal poliomyelitic form. 2. The form resembling Landry's paralysis. 3. The bulbar or pontine form. 4. The encephalitic. 5. The ataxic. 6. The polyneuritic (resembling neuritis). 7. The meningitic. 8. The abortive. This classification is most useful from a clinical standpoint in that it gives the different forms as they are met with in practice and for purposes of description has much to recommend it. Zappert suggested three groups : 1. Cases in which spinal paralysis preponderates and in which the respiratory tracts were eventually involved (Landry's paralysis). 2. Cases with marked cerebral symptoms referable to involve- ment of the cranial nerves or the cerebral cortex. 3. Cases without any special involvement of the central nervous system, but with more or less marked general febrile, meningeal or gastro-intestinal symptoms. Krause suggested: 1. Spinal form (poliomyelitis acuta). 2. A bulbar form. 3. Cerebral form: (a) meningitic; (fe) encephalitic; (c) ataxic. 4. Abortive form. 5. Recurrent or relapsing form. Holt and Howland suggested dividing the cases into cerebral, spinal, bulbospinal, and non-paralytic or the so-called abortive CLASSIFICATION 75 form. Miiller suggested nearly the same, dividing the cases into spinal, bulbar, cerebral and abortive. All the above are based on variations in the symptomatology. Peabody, Draper and Dochez have suggested a classification which is the best for gi\ing a real understanfling of the disease. They suggest three groups: first, the non-paralytic or so-called abortive cases in which the infection does not invade the central nervous system, at any rate, not suffi- ciently to produce any paralysis. The cases with paralysis form the other two groups: first, those in which the upper motor neuron is primarily aflected, and second, the larger group of cases in which the lower motor neuron is involved. In the first paralytic group would come the true encephalitic or cerebral cases, originally described by Striimpell, in which the lesion is probably either in the cortex or in the pyramidal tracts, either high up or in the cord. This form is characterized by a spastic paralysis. In the second group the ordinary paralytic form met with in practice has the lesion in the lower motor neuron, either in the pons or medulla or in the cord, especially in the anterior horn cells. This form shows paralysis of the muscles supplied by the cranial nerves or flaccid paralysis of the muscles of the extremities and trunk. Harbitz and Scheel and others have described cases in which in the same patient there was the occurrence of both spastic and flaccid paralysis, with lesions both in the upper and lower motor neuron. Thus it is seen that any classification that has been suggested up to date occasionally fails to fulfil the requirements. The New York Health Department suggest the following classi- fication: 1. Non-paralytic or abortive cases. 2. Ataxic cases or those with nystagmus in which there are anatomical changes in Clarke's column, the cerebellum or the inter- vertebral ganglia. These cases are very rare. 3. Cortical, in which the lesion is in the upper motor neuron. Also rare. 4. Ordinary spinal or subcortical, in which the lesion is in the lower motor neuron. For purposes of description we have adopted the above and subdivided the last, or ordinary spinal form, into the meningitic, bulbar, bulbospinal, spinal, polyneuritic and the ascending form. The cases described as meningitic may sometimes be incorrectly placed in this classification, but that is not a matter of any very great importance. 76 THE SYNONYMS AND CLASSIFICATION The Non-paralytic or Abortive Form and Preparalytic Stage. — Wickman, in his marvelous monograph, divides the abortive cases into four classes : 1. Those with the course of a general infection. 2. Those showing meningeal irritation. 3. Those with marked pains suggesting an influenza. 4. Those with accompanying gastro-intestinal distiu-bances. To this one might add a fifth, for the purpose of calling attention to it, of an anginal form, or those beginning with definite sore throat. It should be borne in mind that poliomyelitis is a disease which, probably in a very large proportion of cases, does not involve the nervous system to such an extent as to cause special symptoms, and the cases characterized as abortive are merely those which go through a preparalytic stage without having any definite paralysis following. If this point is borne in mind it simplifies the concep- tion and also the description of these cases, for what is true of the abortive cases is equally true of the preparalytic stage of the ordi- nary form of the disease. Doubtless a great number of the so-called abortive cases have muscular weakness or even paralysis of a very limited amount. It is extremely difficult to detect even marked differences in muscular power in very young infants, so that the lesser degrees of loss of power may easily escape notice even after the most searching and repeated examinations. In the New York epidemic of 1916 the symptoms at the onset were very carefully studied in 1500 cases. Figures are as follows: Fever 806 Nausea and vomiting 476 Malaise and weakness 255 Headache 205 Constipation 148 Irritability 125 Diarrhea 122 Coryza 78 Rigidity of neck 74 Tonsillitis 65 Pharyngitis 57 Peripheral pain ^^ . Muscular twitching 57 Prostration 49 Convulsions 47 Cough 45 The onset of the disease is usually sudden. Occasionally the onset is gradual and it may not be possible to tell exactly when the CLASSIFICATION 77 child was taken ill. The severity of the initial synij^torns bear no relation whate\er to the subsequent course of the disease, as one sees a very mild onset followed by most extensive paralysis and even death, and other cases coming in a most fulminating manner which subsequently clear up entirely. The first thing observed about the cliild is that it is ill, and of all the symptoms noted fever is the most constant. There are, perhaps, exceptional cases in which the febrile stage is slight and short and so easily overlooked by ignorant or careless parents; but in cases under care- ful observation the afebrile attacks are certainly most exceptional. The second most notable symptom is the presence of pain, and in children old enough to locate the pain, headache is, next to fever, the commonest symptom. The pains may be in any part of the body and may be so marked as to overshadow all other features of the disease, or they may be so trifling as to be only elicited by special examination, with all gradations in between. The commonest pain next to headache, and of decidedly more value in diagnosis, is a tenderness and pain along the spine and down the legs reaching to the heels or even the soles of the feet, and another very common and suggestive pain is that in the neck and back of the head. If the head is bent forward this is usually greatly increased, causing the child to cry out and resist very markedly. If there is not much pain present it can usually be elicited by bending the legs up and the head forward, so as to flex the spine. In some children the pain is only present when one attempts to move the arms or legs or various parts of the body; in others it is spontaneous and the child cries most of the time with it; and in still others there is a hyperesthesia, so that the slightest touch without any movement whatever elicits an unusual degree of suffering. In some cases pain is elicited on gently squeezing the muscles. In many cases there is slight stifl'ness of the neck and the child assumes a very suggesti^'e attitude, lying on one side or the other, but not on the back, so that the head may be thrown slightly backward. The legs are usually drawn up, although not always. The disease may be ushered in with a convulsion, or convulsions may occur in the course of the disease. The mental condition is extremely interesting. The commonest form of disturbance consists of very marked drowsiness, which is replaced by a most extraordinary irritability when the child is aroused; but when one ceases to examine him he rolls over into his former position and dozes ofif again. Other children are extremely 78 THE SYNONYMS AND CLASSIFICATION restless and irritable and some are wide-awake with a hyperacute mentality or what has been called alert cerebration. With this is a very evident delirium or a tendency to delirium. These cases, in our experience, are of the worst possible type and usually die. In some children there is a very marked delirium — talking, muttering^- and this is accompanied by a tendency to move about in the bed and change the position frequently. Often the moving about is exceedingly suggestive, the child tossing from side to side and not lying in any position more than a few moments, sitting up, standing up, and half-turning from side to side in a perfectly purposeless way. If the child is watched carefully it will very often be seen to have fibrillary twitching of the muscles; at other times whole muscles will tremble. In rare instances the muscle is more or less spastic and may stiffen when the extremity is taken hold of to relax a few moments later. The gastro-intestinal symptoms are not uncommon. Anorexia is the rule. Vomiting may be present and may be so marked as to suggest an acidosis. Constipation is rather more common than diarrhea, but the latter is frequently met with. The throat is often reddened; the redness is general and not limited to the ton- sils, and in some cases there is a considerable amount of coryza and slight suffusion of the eyes. Another curious feature met with both early and later on in the disease is the tendency to profuse sweating. This may be as marked as the colliquative sweats seen in typhoid. Sometimes the sweating is limited to one part of the body, as to the face or neck, or to one extremity, sometimes to one-half of the face. In some cases there may be retention of the urine, and this should always be looked for. Usually, as Wickman has suggested, the disease presents certain dominant features. The cases which are like the course of a general infection have nothing to suggest the diagnosis, or they may have some of the things mentioned above, the general history of the attack being that the child is taken ill suddenly with an attack of vomiting follow^ed by a fever of from 101° to 103° or 104°, or some- times higher, with headache, and feeling very badly, but without any definite symptoms of any kind. This may clear up in twenty- four hours, or it may last two, three, or rarely four days, when the symptoms disappear entirely and the child has nothing whatever to show for it. These cases may be seen in connection with two or three or more cases in a family or group of children, and the diag- nosis is made or suspected by the fact that the child was taken ill CLASSIFICATION 79 at the same time with identical symptoms or nearly so, to one or more definite cases of the disease in the immediate surroundings. These cases present the greatest difficulty in diagnosis. The meningeal form is the most suggesti\'e of all, and one almost immediately realizes that he has either to do with a beginning poliomyelitis, a meningitis, or a meningismus. In these cases, when the patient is examined, it will be found that there is an anterior and posterior stiffness of the neck; Kernig's sign may be present or absent; INIcE wen's sign, elicited by percussing and auscultating the cranium, may be present, owing to the distention of the ven- tricles of the brain with the fluid; and the patient may show a very characteristic sign at this time, or usually a little later, which may be described as follows: If the patient is raised by placing the hands under the shoulders the head will fall back. If the child is told to raise the head when it is sufficiently conscious, it will do so and hold it forward a moment or so and the head will again fall back. This is a sign of very great importance. Brudzinski's neck sign may be present. The arms and legs are flexed on the trunk to theii* full extent and the head is passively flexed on the chest. The patient utters a cry. Brudzinski's leg sign often may be elic- ited. One leg is passively flexed on the abdomen to its full extent when the other leg is drawn up by the patient. In some cases there is a cujious vasomotor distiu-bance which is most often seen in the cases of the meningeal form. This consists of an alternate blush- ing and paling of various areas of the skin. It may be over small spots or over large areas, the part aftected being redder than nor- mal, and then after a varying time it may become paler than the surrounding skin or present a normal appearance. Sometimes the flushing is A'ery transient and is only a momentary wavering flood- ing of the superficial vessels. A fine intentional tremor is frequently noted and is often of help in diagnosis. There is practically never any question in these cases with a meningeal irritability of the advisability of a lumbar punctiu-e, and it should be done as soon as possible, and this usually clears up the diagnosis immediately. The cases with marked pain, resembling influenza, should suggest poliomyelitis. In our experience we have rarely seen cases of influ- enza w4th as much pain, or the kind of pain, as described above, although they do occur. In these cases a lumbar puncture should be done to settle the question of diagnosis. The gastro-intestinal cases are more difficult because one does not always have in mind the possibility of a poliomyelitis. The 80 THE SYNONYMS AND CLASSIFICATION child is taken with a fever with intense vomiting, and if it has had a history of acidosis with vomiting before this the physician may be thrown oflF his guard. In some of these cases, if the child is care- fully observed, some of the special features mentioned above may be elicited, but if they are absent the diagnosis may be impossible. The presence of a very marked diacetic reaction in the urine will incline one to believe that the case is one of acidosis, though it must be borne in mind that any febrile condition will show diacetic acid in the urine, although the reaction is not as marked. The cases with sore throat and coryza are also difficult and prac- tically impossible to tell unless a careful examination elicits some suggestive symptoms or signs. This preparalytic stage, when it does not go on to the develop- ment of a paralysis, is what we have called an abortive case, and may subside in twenty-four hours, or it may last two, three, or four days, occasionally five, six, seven, or eight days, in a few instances longer, but rarely. In some of these cases the convalescence may be slow and the child may suffer with indefinite symptoms for days or even weeks after the attack. These consist chiefly of pain com- ing on at any time, but more often at night, sometimes waking the child up out of sleep. These pains are usually transient and disap- pear either spontaneously or after rubbing the affected parts. In some instances the pain is accompanied with cramps in the muscles. The child may tire readily on exertion even though it has shown no paralysis or loss of power, or the tiring may be localized to cer- tain groups of muscles or to one extremity. When this is the case one might assume that the spinal cells supplying this part have been affected. If the child is old enough to make special tests of the power of the muscles according to the method suggested by Lovett, the diagnosis may be even more certain. The Ataxic Cases. — These form an interesting group and Medin, in his study noted five cases in which there was a transitory ataxia during early convalescence. In four of these there were muscular spasms and tremors in the acute stage of the disease. In almost all his cases there was no atrophy of the muscles and often increased patellar reflexes. Curious association of other things may be met with in the ataxic cases. There may be temporary disturbances of speech, probably due to either bulbar lesions or changes in the peripheral nerves; the patient may stutter or stammer, have diffi- culty in enunciating, and the voice sounds thick and indistinct. Netter has described a case which was associated with ataxia, CLASSIFICATION 81 aphasia and paralysis of the right arm, and Xonno saw a case of status hemiepilepticus and this was followed by a general ataxia of the cerebral type. The pathological changes in these cases has not been sufficiently studied. It is possible that the lesion may be either in the brain or cerebellum, in the pyramidal tracts or in Clarke's columns. Rissler had an opportunity of studying a fatal case and found degeneration of the cells in Clarke's columns. Medin suggested the great similarity between the clinical picture of these cases and the so-called polyneuritic cases and that the condition may be brought about in some cases by changes in the peripheral sensory nerves, although as far as we know this has not been actu- ally demonstrated. He described the ataxia as resembling the ataxia like that seen in hereditary ataxia and not at all as that of a tabetic. The patient totters and staggers, falls easily, walks with the legs wide apart and has great trouble in maintaining his equilibrium. Cases have been described of a very distinctly cerebellar type in which there were almost always involvement of some of the cranial nerves. Cerebellar ataxia is characterized, as Duchenne, of Boulogne, suggested, by a sort of drunkenness of movement and inco- ordination. The patient has a sort of vertigo and in standing totters from side to side and has difficulty in maintaining the equilibrium and is unable to stand on one leg. In walking the patient staggers like a drunken man, places the feet uncertainly and cannot follow a straight line. Ataxia in all instances seems to be transitory, and few of these cases have ended fatally. Medin described certain cases in which ataxia was one of the most prominent symptoms. The following are two clinical histories from his remarkable study: "A boy, aged three years and one month, was taken sick on August 25 with a high fever, restlessness, irritability, sleeping little, and having previously spoken distinctly and well, commenced to talk indistinctly in a thick voice. At the beginning the move- ments were made freely and with no twitching, but there was trembling of the legs in walking. At the end of several days he was somnolent and refused to walk because it caused pain in the legs, and he complained when he was touched. On Septem- ber 2, the note was made that he seemed a little heavy, wished to remain in bed and sleep and complained when he was touched and did not wish to sit up or lie on the right side. He could move the extremities without any strength. When he was forced to walk he complained, walked with difiiculty, staggered behind his mother 6 82 THE SYNONYMS AND CLASSIFICATION when she walked before him, but no signs of any direct ordinary sensations. The patellar reflexes were absent and the muscles did not react to the faradic current. The legs were more cold than the rest of the body. On September 7 he was less sleepy, the examination remained as above, but the patellar reflexes were present and he had had difficulty throughout the illness in having bowel movement. September 1 1 he could, perhaps, walk somewhat better, but with paretic gait, with a tendency to spastic move- ments; no patellar reflexes. September 16, general condition better, walks better, there is no atrophy, patellar reflexes marked on right side, cannot be elicited on left. September 23, walks better, more firmly, but with distinct weakness of the right leg. Patellar reflexes distinct on both sides, but more marked on the right. September 30, paralysis scarcely noticeable in the right leg. October 16, walks perfectly well and is in good health. Diagnosis: infantile paralysis, probably, and acute polyneuritis." "In the other history of a similar condition, it is of a boy, aged three years and seven months, taken sick on September 4. He had always had feeble health and two years before had pneumonia following whooping-cough. His parents, brothers and sisters were perfectly healthy. He had headache, pain in the throat, movements of the face. Became worse in the following days and was very somnolent. This increased until he was no longer able to recognize people about him. September 8, violent piercing cries, no convulsions; no vomiting. September 9, somnolent, cries sometimes as if in pain, especially if one tries to turn him; sometimes he strikes out in different directions with his arms with certain movements, but lies with the legs a little contracted, but moves them about also in quiet fashion. He cannot stand or walk. Holds his head bent backward, but can move his head perfectly. There is no hyperesthesia of the skin. Has a fixed stare without any expression. If he is wakened looks fixedly at objects. No stra- bismus, pupils of equal size; will not make any answer when one speaks to him. September 10, twitching of the tongue and choreiform movements of the right arm. September 11, a general convulsion during the night and nystagmus; twitching of the mouth and of the lower jaw; tonic cramps of the extremities; very somnolent and at the same time holds his head straight. Is very agitated and cries and throws himself about as noted before; evidently cannot speak; nothing else abnormal except a red throat. September 12, free from fever^ less agitated, less somnolent, replies CLASSIFICATION 83 'Yes' or 'Xo/ but very indistinctly; has no nystagmus and the twitching of the tongue and face is less. The following days the temperature remained normal, the somnolence ceased and the child became much more tranquil, the twitching of the face and tongue stopped; there is a convergent strabismus, but it was impossible to tell of what sort owing to the child being frightened. Septem- ber 18, child could speak especially clearly, cried easily, but evidently without pain, understood what was said to him and recovered his memory, seized objects with the hand, but trembled sometimes, cannot walk alone, and has to be supported by both hands, and in spite of that, often falls, movements of the legs are hesitating; patellar reflexes of the legs are exaggerated and there is ankle- clonus, but no h^-peresthesia. September 30, condition was very much improved, according to the opinion of the mother. He was able to talk as in former days, there was no strabismus, no atrophy and no lowering in the temperatiu"e that one could make out. Movements of the arms entirely free and his walk was uncertain and hesitating. October 11, was able to walk without difficulty and was apparently completely restored to health." Transient Ataxia. — Peabody, Draper and Dochez have called attention to a very interesting condition seen in cases where the lesion is definitely limited to the cervical cord, the legs not being paralyzed. In these cases it seemed very probable that the upper neuron was affected, either the pjTamidal tracts or Clarke's column where they passed through the cervical region, and that resulted in a tendency to hold the legs stiffly with increased knee and ankle reflexes and a transient spastic ataxia. The Cerebral Tjrpe. — There is a rare form of the disease known as the cerebral or encephalitic form, or polioencephalitis, in which the lesion involves the upper motor neuron, either alone or chiefly. This leads to a paralysis of the spastic tj'pe ^-ith increased reflexes and no reaction of degeneration. This form of the disease is appar- ently very rare and should not be confused with cases that have, of recent years, been described under these terms in which the chief lesion was in the lower motor neiu-on with consequent 'flaccid paralysis, the cases being described as cerebral owdng to the pres- ence of coma or s^'mptoms suggesting meningitis. One may get some idea of the infrequency of the true cerebral form when one considers that ^Yickman, in the Swedish epidemic in 1905, in over 1000 cases did not see a single instance. Xor was any reported in 84 THE SYNONYMS AND CLASSIFICATION the New York epidemic of 1907, in which over 2000 cases were observed. Peabody, Draper and Dochez did not meet with any in their study. Zappert, in 555 cases, however, describes 5, and various other authors have contributed one or more cases. The first accu- rate description was given by StriimpelP in a lecture in Leipzig in 1884. He called this condition polioencephalitis and noted that in both diseases the chief site of the lesion is the gray matter of the anterior horn in one, and in the other in the corresponding portion of the cerebral cortex; and in considering the etiology he remarked: "After all, one can but ask if all the differences based on purely anatomical reasons between neuritis, polyneuritis and acute infan- tile encephalitis, is not artificial. For my own part, I am of the opinion that all the above-mentioned affections are the same from the point of view of etiology and are only to be regarded as different localized manifestations of a specific disease or caused, at least, by forms superficially closely related." Vizioli^ had previously noted the close relationship of certain cerebral paralyses in children to the spinal form of the disease and the symptom-complex was also described by Pierre Marie in France. StriJmpell described 24 cases all under six years of age and 19 of these were under four years of age, but while most of the cases have been in young children it should not be forgotten that cases have been described in adults. The onset in the cerebral cases is very similar to that seen in the ordinary form, the most pronounced symptom being convul- sions, vomiting and fever. It has sometimes been said that a case coming on with convulsions is liable to be of the cerebral type and while most of the cerebral cases that have been described have had convulsions at the onset, it by no means follows that a chill or convulsion means a case must necessarily develop in a certain way. Most of the cases that have been described have been cere- bral from the onset, but in some there have been prodromes lasting nearly two or three days after which the nature of the disease becomes manifest. There have been instances, however, in which the prodromal stage lasted several weeks, during which time there have been convulsive seizures and then finally paralysis of a defi- nitely cerebral type. The resulting paralysis may be a hemiplegia or a monoplegia and there may be involvement of the face. Facial paralysis is less frequent than the other forms. In some instances 1 Jahrb. f. Kinderh., 1885, p. 173. 2 Deir Emiplegia spastico Infantile (Heine), Morgagni, Napoli, 1880, xxii, 568. CLASSIFICATION 85 there is strabismus. The paralysis usually improves, but generally leaves behind it a certain amount of loss of power and a tendency to contraction. The paralysis is, of course, spastic in character and the reflexes are exaggerated. There is no atrophy and there is no reaction of degeneration. Cases have been described in which there was ataxia without paralysis. Some of these patients may recover more or less entirely or even entirely, as noted by INIedin, but there is a distinct tendency to have signs of motor irritation later on. The late disturbances are usually either a general epi- lepsy' or sometimes epileptic convulsions limited to the paralyzed member; sometimes there is mental deterioration, sometimes moral deterioration, and sometimes speech disturbances or combinations of these, i^thetosis, particularly of the hands, is perhaps the most common of the sequelae. INIedin,^ in his remarkable article, described 4 cases of this type, 2 of which had involvement of the sixth nerve, indicating involvement of the pons as well and giving the connecting link between the cerebral and the spinal forms, and it is of particular importance to know that these were observed in the same epidemic. As an instance of the acute form T^•ith entire recovery we may quote the following case described by Medin: "A girl, aged two and a half years, was taken sick on September 8 with fever and vomiting. Was constipated for the following two days, but otherwise apparently well until September 12, when in the evening she became agitated and had fever. The next morn- ing she remained in bed with sore throat and pains in the right big toe. She got weaker and had trembling in the extremity on the right side. In the evening she had paralysis of the arm and leg on the right side, but still could make incoherent movements. She sighed frequently, had flushed face, was somnolent, sensitive over the entire body, and had some difBculty in lu-ination. The fever persisted for several days; she stammered, having previously spoken perfectly well; the reflexes were normal. She had difficulty in taking hold of things with the right hand, movements of which were uncertain; she dragged the right leg. On September 18 the fever had disappeared, general condition was as before, but the reflexes of the right arm and leg were exaggerated. She spoke as before, and there was no uncertainty in the movements of the right arm. On September 21 she was well, talkative, limped a little with the right leg, and the patellar reflex on that side was exagger- 1 Arch, de med. des Enfants, 1S9S, i, 257 and 321. 86 THE SYNONYMS AND CLASSIFICATION ated. She had made a rapid complete recovery without any symp- toms remaining." During the Baltimore epidemic in 1916 we noted one possibly doubtful case which recovered entirely. The patient was sixteen months old, was admitted on October 15 to the Children's Hospital School. At this time the note was made that "she is a poorly developed child, lying in bed without apparent discomfort. She is irritable, seems quite conscious, and can stand with assistance, but bears the weight on the right foot, holds up the head well, but will not sit. Has no apparent hyperesthesia. Pupils equal, react to light movements, and the eye normal. Neck somewhat stiff; Kernig's sign positive. The arms move perfectly well and the right leg seems perfectly normal. The left quadriceps is weak, but not entirely paralyzed. The reflexes of biceps, abdomen, and ankle can be elicited on both sides. Triceps could not be elicited. Patellar present on the right side and absent on the left." She sub- sequently developed a curious spasticity of both legs; the muscles were not atrophied, "but as soon as the leg is taken hold of there is a marked spasticity, which varied from time to time, and seemed almost voluntary, but which on careful study apparently is not." By the end oi October she was able to walk with a little assistance, could sit up in bed, had regained her normal mental condition, and was perfectly contented. The spasticity disappeared almost entirely during the few succeeding weeks, and the patient left the hospital apparently entirely recovered. The lesions in these cases have been described in a few instances, and while scattered lesions in the cerebrum have been frequently described in the a^utopsy findings of poliomyelitis, extensive foci have been, on the whole, rare. Harbitz and Scheel had an oppor- tunity of studying the brain of a man, aged thirty-nine years, in whom the disease began with headache, fever, and excessive sweat- ing. A few days later he had general convulsions, delirium, stiff- ness of the neck, and vomiting, and in fojir days paralysis of the left hyperglossal, rigidity of the extremities, and increased patellar reflexes, with twitching of the left forearm and fingers later. The patient was comatose and died on the thirteenth day of the disease. There was inflammation and softening of the right temporal lobe, and the microscopic study showed the same histological changes that have been described in the cord in poliomyelitis. They also studied a case in a child, aged seven years, in whom the onset was sudden, with fever, vomiting, drowsiness, rigidity of the neck, and CLASSIFICATION 87 twitching of the arms and legs. The child died in four days and the only microscopic lesions were hyperemia in the acqueduct of Syl- vius and of the cervical part of the cord and an acute encephalitis of the left optic thalamus. Both cases were seen in the Norwegian epidemic of 1905 in Christiania. At this time only 13 cases of acute poliomyelitis were reported in that city, but it seems certain that these were immistakable cases of the cerebral form of the disease. As miglit be expected the lesions are not ahva}'s limited to the upper motor neuron but ma}' occur most anywhere. There have been series of instances in which there was a combination of the flaccid and spastic paralysis. Such cases have been reported by Wickman, Pierre Marie, Oppenheim, Neurath and others. Mobius has described a brother and a sister taken ill at almost the same time with a febrile affection. In one there was a spastic hemiplegia with choreiform mo\'ements; in the other flaccid paralysis. There can be no doubt about the identity of these cases and the other forms of poliom}'elitis as regards etiology, and yet the final test must come by reproducing the disease in monkeys with virus taken from a fatal cerebral case. As far as we know it has not been done up to the present time. Frost and Anderson^ reported an instance in which a flaccid paraplegia subsequently became spastic and the blood of this patient showed the presence of antibodies protective against the virus of poliomyelitis. It is curious to note in connec- tion with this form of the disease that the disease as produced experimentally in monkeys, even if the inoculation is made intra- cerebrally shows a spinal paralysis. The Meningeal Form. — Signs of meningeal irritation are common in poliomyelitis, so much so that La Fetra thinks in making the diagnosis one should alwaj's look for such signs. At times, however, the picture of meningitis may be so marked as to actually obscure the real nature of the disease, unless one is thoroughly familiar W'ith the fact that poliomyelitis may at times resemble menin- gitis so closely as to test the diagnostic skill of even the best clini- cians, and many times to defy diagnosis without a lumbar puncture and examination of the cerebrospinal fluid. The patient may have meningeal s}inptoms from the onset, or the disease may start in the usual manner and sjniptoms of meningitis come after two, three, or four days. As a general rule, the symptoms of meningeal ii'ri- tation clear up in a few days or else the patients die; but in some 1 Jour. Am. Med. Assn., 1911, Ivi, 663. 88 THE SYNONYMS AND CLASSIFICATION the condition may drag along so that it resembles more and more closely tuberculous meningitis. The appearance may be exactly like a tuberculous meningitis, while other cases bear close resem- blance to cerebrospinal fever. At the onset there is vomiting and headache; the patient com- plains of pain, has rigidity of the neck, opisthotonos, Kernig's sign is present, and Babinski's sign may be present, that is, irritating the sole of the foot causes extension of the toes instead of flexion. There is usually strabismus and sometimes tonic or clonic spasms, either localized or general. There is the usual vasomotor disturb- ance, the tache cerehrale may be present, there may be flushing or paling of the skin. There is often fibrillary twitching of the muscles. A lumbar puncture generally clears up the nature of the condition, and description of the changes in the fluid will be found under that heading. Fig. 21. — Opisthotonos in the meningeal type. The Polyneuritic Form. — Cases of this kind have been described by numerous writers, by Medin and Wickman in Sweden, by Netter in France, by Sachs in New York, and many others. The chief interest in this form is in its resemblance to a multiple neuritis. Wickman suggested that these cases may probably be called, more correctly, pseudoneuritic, inasmuch as there is apparently no inflam- mation of the nerves at autopsy, although it is true that compara- tively few reports have been made upon this subject. The chief feature of the disease is the pain, which is chiefly along the nerve trunks, and which may be most intense in character. The origin of this pain is probably due to changes in the nerve roots or the spinal ganglia, or the changes in the cord. There does not seem to be any connection whatever between the amount of pain and the amount of paralysis. Some of the cases with the greatest amount of pain may be paralyzed very little or not at all, whereas others with comparatively little pain may suffer from severe paralysis. CLASSIFICATION 89 The paralysis may be recovered from entirely, in which case, of course, it makes it resemble a multiple neuritis more closely. In some cases there may be a combination of pain and ataxia, there may be pain along the nerve trunks after the acute symptoms of the disease have subsided, although this is not very common. The disturbances of sensation have not been very carefully studied, and apparently are not marked. The age of the patients precludes any accurate observations being made, although some have been made in cases sufficiently old enough to respond to the test for the various forms of sensations. The differential diagnosis is given under the heading of Diagnosis. The Ascending Type, Resembling Landry's Paralysis. — In 1859 Landryi described a case of ascending paralysis of a few weeks' duration, with certain special features which led to his name being associated with this type of paralysis. Landry gives the following summary of his case, which is reported in full: "A man, aged forty-three years, of a delicate constitution, already weakened by a successive series of acute troubles, by the emission of blood, under prolonged diet, experienced, during a slow and incomplete convalescence, a feeling of general weakness which gradually increased, but without any appreciable symptoms of paralysis. Soon there was formication of the toes and fingers, first limited to these parts and without any disturbance of motility. After a period of about six weeks, characterized by these phenomena, the formication of the extremities extended little by little up the members and was replaced by a heaviness and then by a paralysis of the parts, one after the other. The paralysis, which affected only the motility, extended rapidly from the feet to the rest of the legs and then to the arms, to the trunk, to the respiratory muscles, to the tongue, etc. The abolition of movement was so complete that he could no longer move the extremities. Urination and defecation remained normal up to the last moment. The rigidity of the muscles and the excitability was in no way affected. There were no contractions, no convulsions, either partial or complete, no fibrillary tremor, no reflex movements. At no time did the patient complain of pain in the extremities nor along the spine, or in the head and pressure at no time caused any pain. There was no fever, and the intelligence remained normal. Finally, respira- tion became more and more incomplete, s}Tnptoms of asph^-xia 1 La Gaz. hebd. de m6d. et de chir., 1S59. 90 THE SYNONYMS AND CLASSIFICATION became more and more general and the patient died eight days after the onset. The autopsy showed no traces of any appreciable lesion of the nervous system; only a pulmonary involvement or pneumonia of recent date." It is not definitely clear at this time what the disease was that killed Landry's patient, nor is it always clear at the present date what the nature of an ascending paralysis is. Since I^andry's time there has been a disposition on the part of physicians to call all rapidly fatal ascending or descending paralyses Landry's paralysis without reference to the disease which produced the lesion and even some of the cases which recovered have been given this name. An acute ascending paralysis may be poliomyelitis, it may be a toxic ascending myelitis due to bacterial or other poisons, or it may be a toxic polyneuritis. The last-named cases are apt to recover. The ascending myelitis and the poliomyelitis of the ascend- ing type are usually fatal. There is a growing feeling among phy- sicians that most of the cases of the so-called Landry's paralysis are really poliomyelitis, and this is no doubt true, although it is possible there may be other diseases which cause the same picture. There can, however, be no doubt that the cases of ascending paraly- sis, as ordinarily met with, are true poliomyelitis, and this has been verified by studies of many observers. It is, unfortunately, a rather common form of the disease. It forms a characteristic group clinically, but should be grouped as of the bulbospinal type. There is otherwise no reason to separate it. In the cases which have been described as Landry's paralysis, apart from those in which the diagnosis of poliomyelitis was certain, there has been an ascend- ing, seldom a descending, paralysis running, as a rule, a rather rapid course, generally not much fever, and this has been preceded by pain, tingling, numbness, a sense of fatigue, and heaviness in the arms and legs. The paralysis either continues to progress without intermission or it may develop step by step in progressive stages and corresponding roughly to the spinal innervation. When it begins above there is usually some paralysis of the cranial nerves and the patient may die of failure of respiration before the legs become paralyzed. The paralysis is of a flaccid type, with no changes in electric reaction except slight alteration in the reaction to the faradic current. The mind generally remains clear, the rectal and vesical sphincters are normal, but there may be incontinence of urine from an overdistended bladder, owing to the paralysis of the abdominal muscles. . This picture is certainly strikingly like CLASSIFICATION 91 that seen in tlie cases of ascending or (lescencling poliomyelitis. The onset in these cases is as in the others. In many instances, after the paralysis has developed, it spreads upward or downward progressively without intermission. In other cases there is a period of onset, and then a certain amount of paralysis and then a cessa- tion of the disease for a matter of hours or even days, when it starts up again. The patient may be perfectly conscious and may remain so until he dies. Some of the cases remain stuporous tlu"oughout the course of the disease, but, as a general rule, this is not the case. In many, the mind seems to be exceedingly alert in striking contrast to the terrible paralysis. ^Yhen the paralysis starts to spread after it has stopped, the first thing that may be noted is that the breath- ing is more rapid than it has been, that there is hoarseness and loss of voice and some difficulty in swallowing. From then on there is usually a rapid development, one muscle after the other of the legs, trunk, and arms being aft'ected; but the chief s^inptoms seem to come from the involvement of the respiratory centers. There may be paralysis of the intercostals, or there may be paralysis of the diaphragm. It is perfectly possible to have either one and \vA\e the patient recover entirely, sometimes with a paralysis of either group. The paralysis of the respiratory muscles causes a rapid, labored breathing. This may be more or less regular, and is apt to become irregular, and there may be Cheyne-Stokes breathing. The accessory muscles of respiration are brought into play, the nose is dilated, and the picture of respiratory distress very vivid. The head is thrown back and the jaw dropped down and forward, and the expression exceedingly anxious and any attempt at manip- ulation or interference of the child resented greatly if the child is able to make any expression at all. Throughout this time the lungs may be clear, and they remain so until death, or there may be the development of a pulmonary edema. In a certain number of cases, particularly in those in which there is paralysis of the diaphragm, bronchopneumonia develops and may apparently be the cause of death. The heart is also affected, the rate is usually increased, and there are almost always marked changes in the rhythm and the rate, and these change frequently. These cases are nearly always fatal, although occasionally some remarkable recoveries occur. In most infectious diseases death is the result of a toxemia. In these cases of poliomyelitis, death seems to be due to a failure of respiration or the bronchopnemnonia, most usually the former. The patient may be kept alive for many hours after 92 TBE SYNONYMS AND CLASSIFICATION there has been more or less complete paralysis of respiration by the use of artificial respiration, particularly when combined with oxygen. Landolt has kept a patient alive for seventy-two hours, but the patient eventually died. This is the fate of practically all cases in which artificial respiration has been done, but there may be cases in which during artificial respiration the disease may cease to extend and recovery take place. (The reader is referred to the remarks on Paralysis of the Diaphragm and Thoracic Muscles and to the section on Diagnosis.) CHAPTER VII. PARALYSIS. The Onset of Paralysis. — This is a matter of considerable inter- est. In some instances the paralysis is the first thing noted and this led West to speak of it as "morning paralysis," because children are found paralyzed in the morning after having been put to bed perfectly well. The paralysis is most apt to come on during the first four days of the disease and approximately an equal number being affected on each one of the days. The percentage for each day varies somewhat in different epidemics, but is usually between 15 and 20 per cent, of the total number of cases observed. After four days have elapsed the paralysis is less frequent and the num- ber of cases gets successively less until after eight days have passed, when a very few cases may be observed. After fifteen days have passed the danger of paralysis is certainly very slight and cases reported where the interval is longer would certainly come under the class the history of which was to be regarded as doubtful. As a matter of fact, one feels reasonably safe after eight days have elapsed. On examining the child the appearance is often striking. If there is meningeal irritation the child lies on its side with the head thrown back, resents being disturbed and is liable to cry when anyone approaches it. The child usually has a drowsy, wilted look, but sometimes the expression is one of anxiety or fright. If there is no meningeal irritation the child generally lies on its back, has a characteristic curious, wilted, tired expression, the head generally to one side or the other, and the legs drawn up and thrown out in a sort of frog-like attitude. The child is usually drowsy and gener- ally objects to manipulation of any kind. The Diagnosis of Paralysis. — In some the paralysis is apparent. In others it can only be made out with a very careful examination. In adults and older children the diagnosis is usually not attended with any particular difficulty, but in the young it may be a very perplexing problem to determine whether there is any actual par- alysis*or not. 94 PARALYSIS Appearance of Paralysis in Days and Weeks after Onset OF Fever, Massachusetts Epidemic of 1907-10 Cases. Per cent. Preceding attack ' . 2 0.33 Same day 95 16.12 One day ' . . 93 15.78 Two days 103 17.49 Three days 98 16.63 Four days 58 9 . 84 Five days 22 3.73 Six days 51 8.65 Seven days 18 3.05 Eight days 6 1.01 Nine days 2 0.33 Ten days 4 . 67 Eleven days 3 . 509 Twelve days 5 0.84 Thirteen days 1 0.169 Fourteen days . 4 . 67 Not known (fatal) 1 0.169 Two to three weeks 6 1.01 Three to four weeks 1 . 169 Four to five weeks 1 0.169 Eight v/eeks 1 . 169 Two days previous 1 0.169 Not stated 13 2.207 589 Appearance of Paralysis in Days and Weeks after Onset OF Fever. Massachusetts Epidemic of 1910. Same day 20 One day 31 Two days 40 Three days 34 Four days 15 Five days ■. . 11 Six days 11 Seven days 14 Eight days 4 Nine days 2 Ten days 2 Eleven days 2 Twelve days 4 Thirteen days 1 Fourteen days 1 Two to three weeks 5 T'hree to four weeks 1 Four to five weeks 1 Eight weeks 1 200 It is a good plan to watch the child very carefully for some minutes without disturbing it, and then if it is old enough ask DIAGNOSIS OF PARALYSIS 95 it to move its various extremities, and if it is not, to induce movement by gentle manipulation. If this does not succeed it Fig. 22. — Testing the Babinski reflex. (Musser.) Fig. 23.— Testing the knee-jerk. (Musser.) may be necessary to test motion by pinching or sticking with a pin. If there is p^in it is very hard to tell whether the lack of motion is due to the child's not wanting to move or to a real loss of power. 96 PARALYSIS Sometimes the paralysis can be noted by suddenly stretching the muscle, as suddenly straightening out a flexed forearm, and nor- mally the resistance of the biceps is quite apparent, whereas if it is paralyzed, the resistance is wanting. In young infants it is often advisable to hold the child in the hand in different positions, when the paralysis may often be easily detected by the way the limb drops. It is interesting to note how the child will turn instinctively Fig. 24. — Paralysis of left arm and left leg. to get the aid of the force of gravity in making the movement of a paralyzed extremity. Sometimes when no paralysis can be made out the child cannot stand, probably owing to weakness of the gluteal muscles, the quadriceps or the back muscles. The Paralytic Cases. — As we have seen, paralysis is not a neces- sary part of the poliomyelitis infection. It is, however, the most dominant symptom in a large proportion of cases, and the persis- tence of the paralysis with the consequent loss of power and func- SPINAL FORM 97 tion is what most fixes the attention of both the physician and of the layman. A disease may be feared on account of its causing death, but a disease which permits the patient to Hve in an enfeebled condition is even more dreaded and its occurrence in a community makes a much deeper impression. The comparative callousness with which the population watches the annual destruction of infants by the diarrheal diseases is too well known to be commented upon, while 50 cases of poliomyelitis will throw a community of 500,000 into a panicky state of mind. The most striking thing about the paralysis is the fact that it is so thoroughly unsymmetrical; almost any combination of the paralyzed muscles that can be imagined has been described. In a very large number of instances the paralysis is limited to a muscle or a muscle group, or, if at the beginning the whole extremity has been affected, it almost invariably happens that the residual paraly sis is limited to a muscle or muscle group. In a large number of cases there may be weakness of the muscles or of muscle groups without any actual paralysis, or there may be a partial loss of power due to the fact that the muscle is innervated from several nerve roots. The Spinal Form. — The wisdom of the complicated cervical, brachial, and other plexuses becomes very apparent when one studies the paralytic conditions of poliomyelitis. Partial paralysis is par- ticularly well noted in the deltoid, where the anterior and posterior half may work independently. It also has been demonstrated in the pectoralis major and in other muscles. The reason for the predominance of partial over total paralysis seems to lie in the grouping of the cells in the anterior horns of the cord. These cells lie in longitudinal groups, which are largest in the cervical and lumbar regions. Each anterior root contains fibers from several groups of cells, and these fibers are distributed along several nerve trunks. Lesions in the anterior nerve roots or in parts of the groups of nerve cells, unless very extensive, will merely weaken, but not completely paralyze the muscles. The toxin of poliomyelitis very probably reaches the cord through the circulation, chiefly from the branches of the anterior spinal artery, which enter horizontally at difl'erent levels. The planes of destruction are likely to be trans- verse, while the lines of nerve center association are longitudinal, so that a muscle which derives its nerve supply from a group of nerve cells occupying several segments would have some power remaining, as a transverse lesion might easily leave some of the centers intact. 7 Distribution of Paralysis in 868 Cases According to WiCKMAN. Cases. One or both legs 353 One or both arms 75 Combination of arms and legs 152 Combination of legs and trunk muscles •. . . . 85 C^ombination of arms and trunk muscles 10 Trunk muscles alone 9 Paralysis of "the whole body" 23 Ascending paralysis 32 Descending paralysis 13 Combination of spinal and cranial nerves 34 Cranial nerves alone 22 Localization of paralyses not given 60 Distribution of Early Paralysis. Massachusetts Epidemic OF 1910. Cases. One leg only 145 Both legs only 146 One arm only 44 Both arms only 12 One arm and leg, same side 50 One arm and leg, opposite sides 18 Both legs and one arm 32 Both arms and one leg 8 Both arms and both legs 51 Ataxia (transitory) 7 Back . 79 Abdomen 38 Neck 13 Respiration 39 Deglutition 12 Intercostal 1 Face 7 Right face 31 Left face 24 Strabismus 2 Not stated 32 Distribution of Paralysis (1907-10). Report of the Massachusetts Epidemic of 1910. Cases. Per cent. One leg only 324 27.97 Both legs only 272 23.48 Back 154 13.29 Both arms and both legs 129 11.13 One arm and leg, same side 110 9.49 One arm only 84 7 . 25 Both legs and one arm 75 6.47 Face 74 6.38 Abdomen 67 5.78 One arm and leg, opposite sides 33 2 . 84 Respiration 31 2.67 Both arms only 23 1.98 Neck . 11 0.94 Both arms and one leg 10 . 86 Deglutition 7 0.604 Neck and back 6 0.51 Ataxia (transitory) 5 0.43 General 3 0.25 Intercostal 1 0.086 Both arms, back, chest and throat 1 0.086 Total 1420 SPINAL FORM 99 A glance at the preceeding tables will show the general dis- tribution of the paralyses. There are variations in different epidemics; thus, while the legs are most frequently affected there have been instances in which paralysis of the arms predominated, although these are probably very rare. The legs are innervated from the first lumbar through the second sacral segments of the cord, and this particular part of the cord probably has the largest blood supply. Any muscle or any group of muscles may be affected, but in the upper part of the leg the quadriceps femoris is most frequently paralyzed, while in the lower leg the anterior group of perineals, the flexors of the foot, and the extensors of the toes are most frequently involved. The paralysis may involve either one or both legs together, in many instances with paralysis in other parts of the body. It is apt to be rather extensive at first, but almost invariably there is more or less recovery. The flexors of the toes are often not affected, or if they are, are the first to recover. This, together with the force of gravity and the pull of other muscles, results in the very common toe- and foot- drop of particular interest, both on account of its frequency and on account of difficulty in maintaining a correct position to prevent overstretching of the weakened muscles and deformity. In the study made in Vermont by Lovett, the paraly- sis was found, on the whole, more frequently in the hip and dimin- ished in frequency toward the foot — that is, the individual muscles in the upper segment were more often affected than in the lower, but the paralysis was, on the whole, lightest in the hip, next lightest in the thigh and most severe in the lower leg — that is, the propor- tion of total to partial paralysis increases as one went away from the hip toward the foot. The legs were affected nearly equally, the figures being slightly higher for the right, but not essentially different. This is in marked contrast to the predominance of the paralysis of the left arm. In the experience of other observers the left arm has not always predominated. The arms are innervated from the fifth cervical through the first thoracic segment. As a rule, only one arm is affected, and in most instances in which the arm is paralyzed there is also paralysis of the legs. The paralysis of one or of both arms without other involvement may occur, or there may be the added paralysis of the face or of the diaphragm. Paralysis of both arms alone without other involvement is appar- ently of very rare occurrence. The paralysis is most frequent at the shoulder and diminishes in frequency from the shoulder to the 100 PARALYSIS hand. The deltoid and shoulder group are most often affected and the atrophy of the deltoid in some cases may be extraordi- narily rapid and complete; but even when this happens, either complete or more or less complete recovery may, at times, take place. The flexors of the fingers are less frequently affected, or if paralyzed, recover more quickly than the extensors. The recovery of the distal muscles takes place more quickly and more com- pletely than the muscles nearer the trunk. The complete perma- FiG. 25. — Paralysis of the left deltoid muscle, showing the elevation of the shoulder when the patient attempts to abduct the arm. (Whitman.) nent paralysis of an arm is rare, but a more or less complete par- alysis of a shoulder group is not an uncommon result. Lovett has advanced an interesting theory. '^ He believes that the frequency of the paralysis corresponds to the functions of the muscles involved. The right arm is used much more actively than the left, and also for more complicated movements. The legs are used equally. It 1 Bull. Med. and Chirurg. Faculty of Maryland, June, 1915, p. 169. SPINAL FORM 101 seems that the muscles used actively, continuously, and in a more complicated way are more apt to escape than those used less, or for simpler or less complicated work. This difference may be due to the difference in blood supply, which one would suppose to be greater and more free around the centers governing the greatest Fig. 26. — Illustrating the improvement in the range of abduction obtained by transplantation of the trapezius muscle. The line of the incision is shown. (Whit- man.) activity. If this idea is correct, one would expect to find a higher proportion of difference in older individuals. In 24 patients, five years old and younger, there were twelve left arms and twelve right arms paralyzed, a ratio of 1 to 1. In 27 cases over five years of age there were 20 cases of left- arm paralysis and 7 of right, a ratio of 3 to 1. This also agrees with the distribution of the paralysis 102 PARALYSIS in arms and legs, which is most frequent near the trunk, the hip and shoulder muscles performing less continuous and simpler tasks than those of the lower leg or forearm, or of the hand and foot. It has been shown that the muscles of the upper extremities are more severely affected nearest the trunk and less severely lower down, whereas in the leg this relation is reversed, and the largest proportion of severe paralysis is seen in the lower leg and foot. This is probably due to the weight coming on each muscle in the activities of the upright position. In the arm the deltoid, triceps, Fig. 27. — Extreme atrophy of the shoulder, arm and forearm in an adult who suffered from an attack of infantile paralysis at the age uf three. (Starr.) and biceps are all used to hold up the arm against the shoulder- joint, so that the upper muscles have a greater amount of weight to take care of than those lower down. This, of course, is reversed in the legs, as the lower muscles have more weight to carry than the upper ones. Whether this explanation is correct or not is a question, but there is no question about the correlation of the facts. The severity of the distribution cannot be connected with the size of muscles or function of a peculiar sort, nor can it be connected with local changes in the circulation. It does not seem PARALYSIS OF THE BACK MUSCLES 103 to be connected with spinal localization. The distribution as regards the severity is in proportion to the weight to be met by the different muscles, and may be due to the retardation of the recov- ery of the muscles that work against the greatest weight. This has a bearing upon the treatment, and may account for the ill effects on muscular recovery from overuse. Lovett's conclusions are only tentative, and will be subject to further studies; but he seems to have definitely proved that there is another factor besides the plain anatomical distribution of the lesion in the cord, which determines something of the extent and severity of the residual paralysis. Paralysis of the Neck. — This may occur alone or in connection with paralysis of the muscles of the back. Weakness of the anterior muscles of the neck, allowing the head to fall back, is very com- mon and a very useful aid in diagnosis. If a patient is lifted by placing the hands under the shoulders the head generally falls back. If the patient is told to raise his head, if he is able to do it, he will generally hold it raised for a moment or two and then it falls back again and he is not able to bring it up any more. This sign, we believe, was first described by Peabody, Draper and Dochez, and is usually referred to as the "head sign." The child, in many instances, assumes a position with the head thrown back when the muscles are not paralyzed, merely because he finds it a comfortable position. The head falls backward, to the side, or to the front, depending upon which muscles are involved, or if more or less all of the muscles are involved the head falls according to the position in which the child is placed. Permanent paralysis of the neck muscles is usually seen only in very extensive paralysis, but we have seen one instance in which the neck muscles seemed to be the only ones remaining paralyzed. Paralysis of the Back Muscles. — It is very probable, as Miiller has pointed out, that involvement of some of the back muscles is of \-ery common occurrence, but it is very difficult to make out during the acute stage because the child may be too ill to sit up or stand and a loss of power cannot be told from the general weak- ness which goes with any severe illness. In most instances in which the back muscles are affected, so that it is easily made out there is parah'sis of other parts of the body, usually of a very severe nature, but in some instances the muscles of the back may be affected alone. It may be bilateral or unilateral. Where it is bilateral the body topples sidewise, forward or back, and the patient is unable to sit 104 PARALYSIS up. Where it is unilateral the patient sometimes is able to sit up, but there is a marked scoliosis with the convexity to the paralyzed side. In most instances the paralysis of the back muscles clears up. but there are cases in which the condition persists, and is either attended with a scoliosis or the patient may be so severely affected as not to be able to sit up at all. Paralysis of the Diaphragm .^ — The diaphragm is supplied by the phrenic nerve, which comes from the third, fourth, and fifth cervi- FiG. 28. — Paralysis of thoracic muscle. Fig. 29. — Paralysis of thoracic muscle. cal segments. This part of the cord seems to be involved, but very infrequently, except in cases which have a fatal outcome, although it may occasionally happen that the diaphragm may be paralyzed and the patient recover, and the paralysis of the dia- phragm itself may clear up entirely, even if it has been affected as long as one or two weeks. It is usually the last muscle to be involved in the fatal cases, and comes on after the intercostals, in which case death follows soon after. This is most likely to happen in the very extensive cases, or in those of an ascending or descending type. PARALYSIS OF THE DIAPHRAGM 105 Fig. 30. — Paralysis of thoracic muscle. Fig. 31. — Paralysis of thoracic muscle. Fig. 32. — Paralysis of thoracic muscle. 106 PARALYSIS The appearance of the child with a paralysis of the diaphragm is quite characteristic. The respiration is entirely of a thoracic character, and usually the accessory muscles of respiration are brought into action. If the patient is conscious, and they usually are, the expression is extremely anxious, and any movement toward the child to tend to disturb it is resisted as far as it lies in the power of the child to express fear. In normal respiration, with each inspi- ration, the abdomen is pushed forward, whereas when the diaphragm is paralyzed there is a retraction of the abdomen with each inspira- tion. Firm pressure on the thorax causes a very rapid, labored respiration, without producing any diaphragmatic breathing. Peabody, Draper and Dochez have called attention to the fact that in sobbing children the respiration may be entirely of a thoracic nature, and might lead to a mistaken diagnosis. This will not occur, however, if the child is allowed to quiet down before the decision is made. Paralysis of the Intercostals. — The thoracic part of the cord is also rarely involved if one excepts the fatal cases. It is most often seen in cases with very extensive paralysis and those of the ascending or descending type. The patients with intercostal paralysis usually die, but they may recover entirely or they may recover and have a permanent paralysis of the intercostal muscles. The paralysis may be partial or complete. Very curious acute clinical pictures are produced by paralysis of one-half of the chest. The cases" in which there is only a partial involvement may be extremely difficult to detect. In the complete cases the picture is very striking, as will be seen in the accompanying figures of a case that occurred at the Children's Hospital School. The respiration is diaphragmatic in character, and the thorax remains more or less fixed and has a downward movement on inspiration in place of the normal upward and forward movement. Pressure on the abdomen causes labored and difficult breathing. Paralysis of the Abdominal Muscles. — Paralysis of the abdominal muscles is not infrequent. The condition may be somewhat diffi- cult to tell, particularly in very ill children, in which there is almost always a distinct flaccidity of the abdominal muscles. It is fre- quently seen in fatal cases, and very often one is in doubt as to whether there is actually a paralysis or not. The rectus abdominis most usually escapes involvement, but most usually all or part of the external and internal part of the trans versalis may be affected. In many instances the paralysis is transient and disappears after a SPHINCTERS 107 week or two. When the paralysis is partial there is bulging of the abdominal wall at the affectefl part, and this greatly increases when the child cries or coughs or attempts to sit up. When the paraly- sis is more or less extensive it produces a laxness of the abdominal wall which may be very marked in case there is much gas in the intestines, and if it persists the patient stands and walks in a sway-back manner, with the hips flexed, the lumbar spine bent backward, and the abdomen pushed forward in a prominent way. Fig. 33. — Abdominal muscle palsy — poliomyelitis. (Frauenlhal.) If it is one-sided the patient may drop the pelvis to the weak side and the position assumed may suggest that of a patient with congenital dislocation of the hip. The Sphincters.— The sphincters of the bladder and rectum are seldom affected. Vesical paralysis does occasionally occur, but is probably but very rarely permanent, and a permanent paralysis of the rectal sphincter is probably even less frequent. In the patients who are very ill and in those that are extensively paralyzed 108 PARALYSIS there may be little or no control of the bowel, and the patients may be difficult to nurse for this reason; but if the patient recovers control of the sphincter it is almost invariably regained. Involvement of the Ciliospinal Ganglia. — Peabody, Draper and Dochez report one case of extraordinary interest which was appar- ently due to involvement of the ciliospinal ganglia, which is situated in the eighth cervical and first thoracic segment. The patient had a flaccid left arm, and there was a failure of the left pupil to dilate, together with narrowing of the left eyelid. In addition to this there was hemicranial sweating and a hemicranial vasomotor disturbance. The Cranial Nerves. — The First Nerve. — The first, or olfactory, nerve either escapes or the affections of this nerve are not discov- ered, as in a very extensive review of the literature we have not seen any mention either of cases of involvement of it or any record of tests being made to ascertain whether it was affected or not. So many of the acute cases are in very young children that it would be impossible to make accurate observations, but a study among older children and adults would certainly be most interesting. The Second Nerve. — ^The second, or ocular, nerve contains the visual fibers and some to the pupil. In some cases there is photo- phobia which may be particularly marked at the onset or during the first few days. In a few instances blindness has been recorded, but it seems to be a rare affection, and in some cases, fortunately, is of short duration. There is some difference of opinion regarding the state of the eye-grounds, and the subject needs further study. Tedeschi^ observed an instance in which there was optic atrophy in an old case. Wickman reports optic neuritis in a recent case, but Miiller in a study of a considerable number of cases did not find any changes in the eye-grounds, and was of the opinion that if optic neuritis was present the case was not to be classed as a poliomye- litis. This whole subject is one on which we cannot at the present state of our knowledge make any dogmatic statements. The Third, Fourth and Sixth Nerves.- — ^The third, fourth, and sixth nerves control the voluntary muscles of the eye and are not infre- quently affected. There have been a number of instances of com- plete ocular motor paralysis, such cases having been reported by Wickman, and we had an opportunity during the New York epidemic of 1916 to see one instance. In these cases the patient is unable to move the eyes in any direction, and has to depend on lAtti dell' Acadameia di Scienze mediche naturali in Ferrara, 1904. CRANIAL NERVES 109 moving the head and take a chance on the eye coming in line with the object desired to be looked at. The third, or ocular motor, nerve controls all the muscles except those supplied by the fourth, which supplies the superior oblique, and the sixth, which supplies the external rectus. It also supplies the voluntary part of the muscles, raising the eyelid, the involun- tary part being supplied by the cervical sympathetic. There may be either complete or partial paralysis of the third nerve. Ptosis may be present and, in fact, may be the only sign of eye involve- ment. There is also overaction of the frontalis, so that the eyebrow is higher on the affected side than on the good side. There is an external strabismus caused by the sixth nerve being unopposed and an inability to move the eye upward, directly downward or directly inward, although the superior oblique can still give a slight upward and inward movement. The pupil is dilated, due to paralysis of the sphincter, and it does not react either to light or accommoda- tion. Involvement of the third nerve is not the commonest of the ocular palsies, however. The fourth, or superior oblique, nerve may occasionally be affected, but if it is, it is almost always overlooked, inasmuch as the movements of the eye are but slightly affected. The patient, however, has a characteristic diplopia which comes on when he looks downward and outward. The false image is lower than the true, and the upper end is tilted toward the other. If the patient is up and about and looking downward, as in walking down stairs, causes dizziness and the head is held forward and toward the sound side. The sixth, or external rectus, nerve is the most commonly affected in poliomyelitis. This is easily detected, inasmuch as the patient is unable to turn the eye outward beyond the middle point, although all the other movements are normal. The patient also has a diplopia on looking outward. The Fifth Nerve. — The fifth, or trigeminal, nerve contains sen- sory and motor fibers. It is divided into three parts : the first, the ophthalmic division, being sensory nerves, but it also contains efferent pupil-dilating powers from the cervical sympathetic. The second, or superior maxillary, is also sensory, whereas the third, or inferior maxillary, is both motor and sensory. When the fifth nerve is totally paralyzed there is an anesthesia on the same side of the face and scalp, but not extending as far as the angle of the jaw, where the skin is supplied from the cervical plexuses. There is no PARALYSIS anesthesia of the cornea and conjunctiva, of the mucous membrane of the corresponding side of the nose, mouth, and soft palate, and Fig. 34. — Left facial paralysis. Fig. 35. — Slight right facial paralysis Note wrinkling of nose on the left side. as far back as the circumvallate papillae. Behind these the tongue is supplied by the glossopharyngeal. There is a tendency for food Fig. 36. — Slight left facial paralysis. Fig. 37. — Right facial paralysis. to collect on the affected side, owing to the anesthesia, even though the motor power of the buccinator muscles is unimpaired. The CRANIAL NERVES 111 Fig. 38. — Left facial and hypoglossal paralysis. Fig. 39. — Right facial paralysis. Fig. 40. — Left facial paralj"sis. 112 PARALYSIS anesthesia extends to the middle Hne and the patient has a sensation as if he were drinking out of a broken cup. There is impairment of taste in the anterior two-thirds of the tongue. Owing to the fifth nerve supplying sensory fibers to the facial muscles there is an apparent or pseudofacial paralysis. The motor fibers supply the masseter, temporal, and both pterygoid muscles, as well as the tensor tjmipani, masseter, mylohyoid and the anterior belly of the digas- tric. The atrophy of the temporal and masseter is usually very apparent and the zygoma looks abnormally prominent. There may be dryness of the eye on the affected side; there may be no sneezing from the application of snuff to the nasal mucous membrane and the sense of smell on the affected side may also be impaired. In poliomyelitis the motor part of the nerve is most apt to be affected. There has been but little noted about the sensory involvement. The Seventh Nerve. — The seventh, or facial, nerve is perhaps the most frequently affected of all. The paralysis of this nerve in poliomyelitis can very easily be mistaken for the paralysis due to neuritis after it leaves the stylomastoid foramen, the so-called Bell's paralysis, but in poliomyelitis there is very apt to be an accom- panying sixth nerve involvement in the bulbar lesions affecting the facial nerve. Taste and hearing are unaffected. If the lesion is within the Fallopian aqueduct there is a loss of taste in the anterior two-thirds of the tongue, and sometimes disturbances of secretion of saliva of the submaxillary and sublingual glands, and there may be unusual sensitiveness to loud sounds. If these symptoms are present it might be regarded as a point against the condition being due to poliomyelitis. Involvement of the facial nucleus affects the symmetry of the face even at rest, and this is very much exaggerated on moving the facial muscles. Asking the patient to laugh or to whistle, or, in some children, causing crying, will usually bring out the loss of power very plainly. The patient cannot wrinkle the forehead, the eye is open and cannot be shut, tears run over the cheek, and the irregular involuntary winking of health is absent. Sometimes the eye is shut during sleep, or almost so, supposedly from the relaxation of the levator palpebrse. The tip of the nose may be drawn a little to the sound side and the mouth is also pulled to the sound side, whereas on the other side it may droop and saliva may run from it. The labial consonants are pronounced with difficulty, and during chewing the food is apt to collect between the teeth and the paralyzed cheek. In poliomyelitis there is very fre- CRANIAL NERVES 113 qiiently involvement of some of the other cranial nerves as well, especially the sixth or the twelfth. The Eighth Nerve. — There are very few observations dealing with the ear in poliomyelitis. The changes one would expect to find would be either deafness, tinnitus, or vertigo. In a few instances in which the ear was examined it was either found to be normal or there was slight injection of the bloodvessels, particularly near the insertion of the handle of the hammer. Special study of the ear in future epidemics will probably throw a great deal of light on the subject. Ninth Nerve. — When the ninth, or glossopharyngeal, nerve is affected there is difficulty in swallowing and a loss of taste and common sensation on the posterior third of the tongue on the affected side and also on the soft palate. Common sensation is also lost in the upper part of the pharynx. It is quite probable that the difficulty in swallowing seen in the cases that ultimately prove fatal, may be due to involvement of the ninth nerve. The Tenth Nerve. — The tenth, or the vagus or pneumogastric, nerve supplies the pharynx, larynx, esophagus, heart, lungs, stom- ach, and part of the intestines and spleen. It contains both motor and sensory fibers. If one pneumogastric is affected there is paraly- sis of one side of the palate, which can be made out by asking the patient to say "Ah" when the palate is pulled up on the sound side and there is a one-sided paralysis of the larynx and anesthesia of the larynx on the affected side. The voice is apt to be hoarse, but not entirely absent. If both nerves are affected there is profound alteration of the respiration and circulation. The respiration is slow and irregular, and the heart beats very irregularly, and there is usually pronounced tachycardia. In some instances there are spells of respiratory distress and accompanying tachycardia, which have been described by Medin, Wickman and others. In some cases there is Cheyne-Stokes breathing. The Eleventh Nerve. — ^The eleventh, or spinal accessory, nerve is entirely motor and supplies the sternomastoid and part of the trapezius. Paralysis of the sternomastoid shows itself in rotating the head, when the sternomastoid does not stand out prominently as it does normally. The trapezius paralysis causes a downward and outward displacement of the scapula, so that the inner border is no longer parallel to the spine, and when the patient presses the shoulder back the scapula is unevenly placed toward the median Une. 114 PARALYSIS The Twelfth Nerve.— The twelfth, or hypoglossal, nerve is a motor nerve supplying the muscles of the tongue and in it there are branches from the first and second cervical that go to the depres- sors of the hyoid. The diagnosis is easily made, inasmuch as the tongue is pushed to the paralyzed side and there is usually marked atrophy of the affected part. There may be involvement of the muscles of the lips, usually bilateral, due to involvement of the low- est cells of the facial nerve, which are in close connection with the nucleus of the hypoglossal. Fig. 41. — Left facial and hypoglossal paralysis. Atrophy of left side of tongue protrusion to the left. The Frequency of Cranial Nerve Affection. — Since Medin called attention to the fact that the cranial nerves might be involved, there has been an increasing number of cases reported. As early as 1836 Badham noted ocular palsy. There are probably varia- tions in different epidemics. In 1916, in a small epidemic in Balti- more, there was an unusual number of cranial nerve involvements. In the Swedish epidemic of 1905 Wickman collected 42 cases out of 685. These were arranged as follows: Cranial nerve affections associated with spinal Cranial nerves nerve affection. alone affected. VII 12 14 XII 9 9 Eyes 5 3 VI 4 2 III 4 2 IX-XI 5 4 V 2 II 1 42 34 BULBAR FORM OF PARALYSIS 115 In 338 cases at the Queensboro Hospital, in the New York epidemic of 191G, there was cranial nerve involvement in 46 cases, arranged as follows: Cranial nerve affection. Optio 2 Oculomotor 2 Fourth 1 Abducens 12 Facial 26 Glossopharjaigeal 2 Hypoglossal 1 46 Conjugate paralysis of eyes in 2 cases. The Bulbar Form of Paralysis. — The cases which show localiza- tion in the pons and medulla are generally called cases of bulbar paralysis and those cases occurring acutely with fever are, per- haps, to be regarded as poliomyelitis. There is no question that both from a pathological and epidemiological point of view that bulbar paralysis may be of poliomyelitic origin and be the only invohement. More frequently it is associated with involvement of the spinal cord, and such cases are then described as bulbospinal. We have considered the various involvements of the cranial nerves, but it is necessary to add a word about some of the combinations. When occurring alone or in connection with involvement of the spine, the bulbar lesions are almost invariably unilateral, although occasionally bilateral cases have been reported. All sorts of com- binations may be observed, the commonest form being the facial paralysis due to lesions of the seventh nerve. There may be vari- ous combinations of eye-muscle affections, either alone or with other paralyses, and there may be changes in the pupil; sometimes there is nystagmus, there may be marked changes in the voice, varying from slight hoarseness to complete aphonia, but this, in most instances, clears up; sometimes it may be of very transient duration. There may be slight difficulty in swallowing, there merely being a tendency to have the food enter the larynx, or, as children usually express it, to swallow the wrong way. Sometimes liquids can be swallowed easily, but not solid food, but at other times the inability to swallow may be so complete as to necessitate gavage. In some of these cases, even after the patient has been fed for five to ten days, the ability to swallow returns. The severity of the bulbar cases seem to be greater when they are associated with involvement of the cord. Curiously enough the mortality in these 116 PARALYSIS cases does not seem to be any greater from the close proximity of the lesion to the vital centers than in the cases in which the lesion is elsewhere. In some instances the nerves pass through the pons and medulla and seem to be involved, such instances having been reported by Wickman, Zappert, Spieler, Peabody, Draper and Dochez and others. In one of Wickman's cases there was involve- ment of the eye muscles, the left side of the face, the right side of the tongue, and a cerebellar ataxia. In another case there was involvement of the left facial and hypoglossal, with slight scanning in speech, some ataxia of the arms, and exaggeration of the deep reflexes of the legs. Peabody, Draper and Dochez have called atten- tion to the slight spastic ataxia which this type of cases may have, and which is noted under the heading of Ataxia. Deformities. — During the second stage of the disease, sometimes even during the first, there is a very marked tendency to deformity. The ones produced by gravity and, perhaps, noted the earliest, such as toe-drop and foot-drop, and it is exceedingly important to try to prevent this, as far as possible, by the method spoken of in the treatment of the disease. The second factor in the production of deformity is having one muscle or one group of muscles paralyzed, and as a result of there being no resistance to the opposing muscles, the tendons and muscles are gradually stretched, made abnormally long and pulled out of position on the diseased side and correspondingly shortened on the healthy side. This, if left to itself, will produce the most extraordinary deformities, as may be seen in the various illustrations. If all the muscles are paralyzed a flail-joint usually results. As time goes on and the child grows, two other factors enter into the deformity; the flrst, the atrophy of all the tissues, including even the bones, and the efi^ect of growth, the two together often producing most remarkable results. The growth of both joints and muscles is along the line of least resis- tance, so that the long bones may be bent out of shape, the joints distorted sometimes beyond recognition, and there may be atrophy with this, so that at first sight it may be exceedingly difficult to orient oneself. The longer this is allowed to go on without any treatment the worse it gets, and in some cases even with treatment the deformity may reach most discouraging proportions. The paralyzed extremities may grow at a very much less rapid rate than those on the good side, and there may be a very considerable shortening as a result. This may come on within a very few months, even as much as half an inch to an inch may be noted in this length bjEP'ORMltlES 11? of time. Seeiigmiiiler called attention to the elongation of tlie bones of the leg which he believed to be due to the epiphyses suffering retraction instead of the normal compression. Sometimes the lengthening is real, at others only apparent. The bones themselves Fig. 42. — Old anterior poliomyelitis; hypoplasia of the right half of the shoulder- girdle, thorax, and right upper extremity. (From the Medical Clinic of the Montreal General Hospital.) are apparently not more liable to fracture than normal bones, but there is a relative increase of the medullary part. The skin, espe- cially in the older cases, usually adheres to the connective tissue under it, and the difference in temperature of the good and affected 118 Paralysis side may, in some cases, be as much as ten degrees. The skin and tissues heal rapidly after operation and fractures and unite the same as a normal bone. When one has made a diagnosis of the nature and extent of the paralysis the deformity that will result from neglect can easily be foretold. The results seem to be pretty uniformly the same, and depend upon the muscle paralysis and the extent of the paralysis. The deformities that occur will be found largely as follows : Those of the foot are taken from an article by Lucas and Lovett.^ Foot. Varus Peronei. Anterior tibial. Posterior tibial. Valgus Flexor longus hallucis. Both tibials. , Whole leg. Equinus Anterior muscles paralyzed or weak. Complete paralysis. Anterior muscles with persistence of flexor longus Eqxiinovarus hallucis. Anterior and external group. Eauinovalaus / -^"^terior and internal muscles. \ Anterior muscles and weight-bearing. Calcaneous Posterior muscles. Calcaneovalgus Posterior muscles and one or both tibials. Knee. Genurecurvatum Posterior thigh muscles. Permanent flexion Quadriceps. Hip. Luxation See dislocations. Permanent flexion Extensors of thigh. Permanent adduction Glutei. Hand. Flexion of fingers and wrist Paralysis of all extensors. Extension of wrist Flexors of forearm. Claw-hand Extensors of forearm. Elbow. No deformity (Seeligmiiller) . Shoulder. Subluxation Deltoid. > Jour. Am. Med. Assn., November 14, 1908. DISLOCATIONS 119 Trunk. Dorsal scoliosis Paralysis of one side of back muscles or other — erector spinse group. Kyphosis Extensor of back. Lordosis Abdominal muscles. Dislocations. — The only joint that suffers with a true dislocation is the hip, but there may be looseness of the muscles and of , the joint capsule of some of the others. These may gradually be stretched by the force of gravity until the bones are completely Fig. 43. — Anterior pohomyelitis. Extreme flexion deformity at the hips, inducing Quadrupedal locomotion. (Gibney.) pulled out of place. This is well illustrated in the cases of paralysis of the deltoid, in which there may be a subluxation of the humerus. In the hip, in a case of extensive paralysis of the muscles about it, there may be a very loose capsule and either a partial or complete dislocation when the leg is adducted, or when it is moved upward or downward. Forward dislocations have been described, but are apparently very rare.^ In some instances the bone forms a new 1 Sever: Boston Med. and Surg. Jour., August 31, 1911. 120 PARALYSIS Fig. 44. — Poliomyelitis, causing gemirecurvatum, (Whitman.) Fig. 45. — Poliomyelitis. Paralj^sis of muscles at the hip allows subluxation of the femur. (Whitman.) DISLOCATIONS 121 socket which may be of more or less service. In others there is a partial socket formed from which the head of the bone slips about and in some there may be a very remarkable atrophy, even going as far as to have complete disappearance of the head of the bone. Fig. 46. — Onset at eighteen months. No attempt at preventing deformity. Patient aged twelve. Walked on his hands. Condition on entrance to Children's Hospital School, Baltimore. The diagnosis is, perhaps, best made by the .r-ray examination, but the same rules used in determining ordinary dislocations may be applied, especially the shortening and the trochanter being above Nelaton's line. CHAPTER VIII. SPECIAL FEATURES AND SYMPTOMS. The Incubation Period. — The incubation period in the experimental disease as produced in monkeys, varies from two days to over six weeks, but usually they develop the disease within two days to two weeks. The incubation period in the human being is usually short, generally under eight days. It has been variously asserted by various observers. Wickman places it at from one to four days, Miiller at from five to ten days, with an average of about a week, whereas Flexner puts it at from two days to two weeks, or occa- sionally longer. Onset without Prodromata. — In about 5 per cent, of the cases the paralysis may be the first symptom noted. In a very small propor- tion of these cases there does not appear to have been any preceding symptoms of any kind, but, as a rule, if the history can be obtained it will be found that there has been slight fever or vomiting or some other sign of indisposition. In many cases, owing to the ignorance or carelessness of the parents, slight symptoms are ignored, and the loss of power therefore given as the onset of the disease. In some of these cases the usual symptoms of the disease may make their appearance after the onset of the paralysis. Cases with Remissions of Symptoms and Delayed Paralysis. — In the preparalytic stage there is not infrequently a remission of symptoms with a subsequent recurrence. The remission generally lasts a day or two and then the symptoms return in a more intense form. We have seen children who were said to have been in bed a day or two and out on the street the next day, and on the following day profoundly ill with the onset of paralysis within a very short time. A similar remission may occur after the child is paralyzed. There may be a decided betterment both in the general symptoms and sometimes in the paralytic condition, and also in the changes in the spinal fluid, and then after one or several days there may be a recrudescence of the fever and the symptoms, a greater loss of power, and return of abnormal changes in the spinal fluid. Relapses or Recurrences. — There have been a few curious instances reported by various observers, including Medin, Leegaard, Auer- fEMPERATURE 123 bach, Xeurot, Forster, and Schwartz, in which after a child appar- ently had recovered from an attack and after an interval of even weeks or months there was a recurrence of the disease with increased paralysis. The nature of these cases is not definitely understood; whether it is simply a flaring up of the original infection or whether the first attack did not produce an immunity and the child suffered with a subsequent infection. In any event they are of very rare occurrence. Second Attacks. — The immunity produced by one attack of the disease seems to be almost perfect, but there are instances on record in which very definite second attacks have occurred in indi- viduals who previously had the disease. Two such cases occurred in the Xew York epidemic of 1916. These cases should, perhaps, be distinguished from the relapses or recurrences. (See same.) Eshner^ has made a study of this subject and also refers to the other nervous diseases which may occur after poliomyelitis. Most of the cases that have been reported would come under this class. Eshner, however, reports a case in which eleven years elapsed between the two attacks. The first case was undoubted polio- myelitis. The second attack, which occurred at thirteen and a half years, attended with weakness and wasting in both hands, transitory on the right side and persistent on the left. It was some- what doubtful, inasmuch as it followed an injury due to a fall, and the paralysis may possibly have been of peripheral origin rather than spinal. The Temperature. — Fever is the most constant!}' observed s\Tnp- tom, and we are of the opinion that the so-called afebrile cases are merely those in which the febrile period has been transient and overlooked. It is important to note that the height of the tem- perature and the ultimate outcome of the case bear no relation to each other. There may be extremely high fever, particularly at the onset, and the child may recover entirely, while in other cases with the most extensive paralysis the temperature may never be very high. The temperature, as a rule, starts at the beginning of the disease and varies between 101° and 104°; in some cases the temperature is even more than this, while in others there may be hyperpyrexia, 105° to 106° or even more. Temperature, as a rule, does not last long, usually from two to five days, sometimes seven or eight, and, very rarely, for ten. It may fall to normal rather 1 Med. Record, September 24, 1910, p. 52G. 124 SPECIAL FEATURES AND SYMPTOMS suddenly or it may drop gradually with decided oscillations. Some- times the temperature drops below the normal and may remain subnormal for several days or even several weeks. In other cases the temperature does not quite reach the normal point, although it is near it, and this may also persist for days or even for weeks, but without any apparent effects. In a considerable number of cases, the so-called dromedary cases of Draper, the temperature returns to normal and then goes up again, usually with the onset of paralysis. In some of the cases in which there is paralysis the temperature may reach normal or near it, and then after several days, usually four or more, there is a recrudescence of the fever, with an increase in the paralysis and general symptoms. A curious thing about many of the cases is that they do not look as though they had temperature, but on taking it, it is found to be above normal. Prostration. — There are great variations in the amount of pros- tration present; in some there may be little or none, whereas in others it may be very marked. In some instances the prostration is pronounced, even from the first; it may be continuous or it may remit, and the child be up and about and then have to go to bed again. In the milder cases the condition passes off quickly, whereas in the severer ones it may last a week or even two weeks. Stupor. — Unfortunately, many authors have used the term encephalitic or cerebral and have applied that to all cases with stupor. These terms are best limited to the cases in which there are lesions of the upper neurons with spastic paralysis as first described by Striimpell. (See same.) The ordinary paralyses are due to either bulbar or spinal lesions, or both, and the stuporous cases may be regarded as belonging to this type with the added .mental condition. Whether these changes are due to the changes in the blind areas of the brain or not has not been definitely settled at this time. These patients may be in profound coma, with open eyes, an expressionless mask-like face, and slight retraction of the head. In others the condition is not so bad, but the child is in a very profound sleep, with the eyes moving slowly under the closed lids. In a general way they resemble very closely cases of tuber- culous meningitis, and the diagnosis between the two conditions may be a matter of considerable difficulty. The child can generally be aroused partially, and if not, when disturbed, it shrugs the shoul- ders or moves the arms or head, showing distinct irritability, and as soon as undisturbed relapses into its state of coma. In others DELIRIUM 125 the condition is less stuporous, and they merely have the appearance of a child in a profound sleep, such as might be induced by nar- cotics. This condition usually lasts from three to six days, and the child may come out of it suddenly just as if it had been asleep for that period of time, or more often the return to consciousness is gradual, occupying a matter of hours or even a day or more. There does not seem to be any relation of the stupor to the temperature. Cases with high fever may have little or none, and, on the other hand, some of the most profoundly comatose may have little or no fever. Headache. — This is one of the commonest symptoms, and is met with in practically all cases in which the child is old enough to describe sensations. In most instances the headache is of mod- erate severity, but at times may be very intense, suggesting that seen in meningitis. The pain may be over the entire head, but is often limited either to the frontal or occipital regions. The patient often complains of pain in the back of the head and the neck. Delirium.^ — As a rule the mental condition is one of somnolence; the patient may be delirious, although this is usually of short dura- tion and not very severe. The more common condition is a mental confusion like that seen in meningitis. Of more importance is a condition of mental exultation which we have occasionally seen and which apparently is of very grave import. The patient, who may be profoundly ill, in place of being somnolent or confused is talkative, is excited and sleepless. In all instances which we have seen in which the patient was very ill and in which this condition existed there has been a fatal outcome. In adults and older children there is occasionally a stage of excitement which may be noted at the onset and which is out of all proportion to the other symp- toms. There is a vague anxiety of some great impending evil, together with mental disturbance; a state somewhat suggesting the condition of a person with beginning rabies, a point which may be borne in mind in considering the diagnosis. Restlessness and irritability are very common and pronounced symptoms, and may be the first thing noted. As a general rule the child will be quiet and only restless and irritable w^hen disturbed, but in other cases there is a very marked restlessness, especially at the outset, and the patient may move about in the bed from side to side and up and down and getting up and down again and again in a perfectly purposeless manner. This in itself we regard as a very suggestive sjinptom. 126 SPECIAL FEATURES AND SYMPTOMS Convulsions. — ^While general convulsions are not often seen, although they may occur at the onset, especially in young children, Medin thought they occur only in cases that turn out to be enceph- alitic; but there are certainly exceptions to this. They have occa- sionally been noted in the course of the disease and preceding the ataxic sjrmptoms. In the Hesse-Nassau epidemic there were a number of cases in which there were epileptiform seizures without loss of consciousness, and also more tonic spasms. Miiller has reported an instance in which there was severe epileptiform convulsions with unconscious- ness. Twitching. — Twitching of the muscles is comparatively common. It may consist of a quick contraction of an individual muscle or of a group of muscles, sometimes of an entire extremity. It is usually noted early in the disease before the onset of the paralysis. There is a faint fibrillary twitching of the muscle fibers, frequently noted in connection with vasomotor disturbances, which is exceedingly suggestive and is often seen, particularly in the meningitic type. Tremor. — ^Attention was called to tremor by Wickman, and may have certain value in diagnosis in the early cases. It is seen in the initial stage, is perhaps best observed in the hands, and consists of a slight, intentional tremor, which is absent in repose. Nystagmus. — This has been noted frequently in connection with paralysis of some of the cranial nerves and in cases with ataxia, and, perhaps, occurs independently of either. The condition is usually transitory and the nature of the central lesion producing it is not perfectly clear. Reflexes. — ^The deep reflexes are absent when there is complete paralysis and may be diminished when there is- partial paralysis. In the true cerebral type of the disease the deep reflexes may be exaggerated and Babinski's sign present. Disturbances of Taste. — ^As far as we know these have never been studied, but it would seem highly probable that in affections of the fifth or ninth nerves that they would occur. In older children and adults studies might easily be undertaken, and the results would be extremely interesting. Speech Disturbances. — ^Apart from the disturbances of speech mentioned under the heading of Bulbar Paralysis, there are other but little studied affections. Among these may be mentioned scanning speech, similar to that which one sees in multiple sclerosis. This is usually transitory, and is generally seen in the cases in which PAIN 127 there is ataxia. We have under observation one child, three years of age, with the most distinct scanning speech that it has had ever since it could talk, the paralysis coming on at the end of the first year. In addition to this the child has a slight spastic paralysis with marked increase in the tendon reflexes and very marked ataxia, being unable to walk or stand without assistance. The other disturbances of speech are probably very rare and have attracted but little attention. Pain. — Pain or tenderness is one of the striking features of the disease. This has been noted in practically all epidemics as well as in the sporadic cases. In the Xew York epidemic of 1907 the pain was distributed as follows: Lower extremities 248 Upper extremities 49 Trunk and spine 104 In the neck 27 In the face . 1 General hyperesthesia 4.3 In the Massachusetts epidemic of 1910 the pain and tenderness was present in 184 cases and absent in 16. A more careful study of this symptom than its mere location or occurrence shows that there are a number of different sorts of painful sensations. There may be spontaneous pain, there may be pain on pressure of the muscles or nerve tracts, there may be hyperesthesia of the skin, and perhaps most important from the standpoint of diagnosis, pain may be elicited by any motion which tends to bend the spine, such as testing for Kernig's sign or in bending the head forward upon the chest. These motions almost invariably elicit pain, and the patient resists attempts to flex the legs on the abdomen or to bend the head forward or to have the spine flexed. The patient often fears this pain may be produced and may lie with the head somewhat thrown back and the spine somewhat extended. The spontaneous pain is extremely variable. Some cases are seen in which there is no pain whatever tliroughout the whole course of the disease, while in others the pain may be of the most intense character, and in the same way there are great variations in the length of time the pain lasts; it may be transient, and consist of lightning-like stabs of pain, or it may be constant and may last from a few hours to a few days, and, in some instances, as long as six weeks, and occasionally even longer. In most instances in which recovery from the paralysis takes place early the spontaneous pain 128 SPECIAL FEATURES AND SYMPTOMS has disappeared by the time the power has returned. The cases in which the paralysis is of longer duration the pain has usually ceased in from one to three weeks. In some patients the pain is not very definitely localized, particularly in the younger children; in some it seems to follow the nerve tracts or certain peripheral nerves and suggests a neuritis, and when this is the dominant feature it has given rise to a special classification of polyneuritic cases. Headache is also a spontaneous pain, especially noted at the onset of the disease. The pain produced by motion is apt to keep the children prone for days or weeks. In ordinary cases of illness in children, as soon as the child feels the least bit better it wants to sit up and move about. In poliomyelitis the children are perfectly content to lie and play with such simple toys as they may be able to handle. They may be perfectly contented as long as they are let alone, but as soon as they are approached they show every evidence of fear of being disturbed or an attempt to make them move. In some cases there is very definite tenderness or pain to be elicited by firm pressure on the muscles or firm pressure over the nerves, and this may exist without any tenderness of the skin. In other cases there is definite hyperesthesia, and the patient cries out at the merest touch to the skin. These areas may be more or less localized or the condition may seem to extend through most of the body. It seems to be particularly present in the legs. In some instances the child cannot bear the pressure of the bedclothes, and wire frames have to be supplied to keep the clothing from coming in contact with the skin. This whole subject of pain in poliomyelitis could be restudied with advantage. In most epidemics there has been so much thrown on the physicians and nurses that only superficial studies have been undertaken in most instances. Pain and Tenderness. Massachusetts Epidemic of 1910. Cases. Pain or tenderness was present in . . . 469 Pain or tenderness was absent in 42 Pain or tenderness was not stated in 90 601 OTHER SENSORY DISTURBANCES 129 Pain or Tenderness Lasted. Casns. No pain 42 One da\- or less 9 Two cla\'s 14 Three days 20 Four days 15 Five days 10 Six days , 6 One week 35 One to two weeks 41 Two to three weeks 32 Three to four weeks 18 Four to five weeks 8 Five to six weeks 4 Eight to nine weeks 5 Nine to ten weeks 1 A few days 25 Until death 45 Present when report was made 181 Not stated 90 601 Disappear-\nce OF Pain and Tenderness (1909-10). Massa- chusetts Epidemic of 1910. Cases. Per cent. One day or less 11 1.82 Two days 22 3 . 64 Three days 29 4.801 Four days 15 2.48 Five days 14 2.31 Six days 3 0.496 A few da j's 28 4 . 63 One week . 59 9 . 76 One to two weeks 91 15.06 Two to thi-ee weeks 46 7.61 Three to four weeks 33 5 . 46 Four to five weeks 1 0.16 Six to seven weeks 1 0.16 One to two months 28 4 . 63 Two to three months 5 . 82 Several months . 3 . 496 Until death 39 6.45 Present when report was made 175 29.13 Total 603 Other Sensory Disturbances. — These have not been studied either, except by comparatively few observers, and not with any very great degree of thoroughness. Various paresthesias have been described and older children and adults sometimes complain of numbness. Wickman relates a case in which there was diminution of the pain sense from the hips down and paresthesia of both legs. It is inter- esting to note that in this case the feet showed a definite diminution of temperature sense of the feet. Other cases have been described 130 SPECIAL FEATURES AND SYMPTOMS in which there was complete anesthesia, and loss of electric reaction has also been noted. We are so accustomed to thinking of polio- mj^elitis as a disease affecting the motor part of the nervous system that in spite of the mass of evidence to the contrary the sensory side of the nervous system has been very largely neglected. Sweating, — ^This is very common and varies from a moderate perspiration to intense colliquative sweats involving the whole body. It very often happens that this sweating is limited to certain areas; to the face or neck, sometimes to one-half of the face, to one extremity, to the hands and feet. As the patient recovers the sweating usually disappears, but it occasionally may persist for some time as a disagreeable feature. There is apparently no relation between the sweating areas and the paralysis. Dry Skin. — Higier has described a few cases in which there was unusual dryness of the skin of the paralyzed extremities. Eruptions. — There is no typical eruption of poliomyelitis, although some authors have described skin eruptions in connection with the disease. Erythema of an irritative type may be noted, particularly about the head, neck, or chest, but this is usually more or less tran- sient, and is of very common occurrence in sick children who have fever, without reference to the cause. Of course, complicating skin diseases may be noted, most commonly itch, pediculosis, the result of mosquito bites, and eczema from the lack of care. The paralyzed extremities are usually cold and show a bluish-white mottling. In cases with meningeal symptoms the tdche cerebrale may be noted after stroking the skin. First a red line appears and then the center of this red line becomes lighter, while the edges remain red. In other cases there is simply a red line which fades quickly, and there is frequently alternating blushing and paling of certain areas of the skin. These may be of very short duration or may last for a considerable length of time. Herpes, usually of the lips, has been occasionally noted. It is apparently, however^ rare in poliomyelitis, and this was formerly suggested as a differential point between it and cerebrospinal fever. Joint Swellings. — Occasionally swelling of the larger joints have been noted in the course of poliomyelitis. Such cases have been noted by Wickman, Hoffman and Spieler. The chief importance of this complication is the possibility of mistaking the disease for an acute rheumatism or arthritis. Emotional States during Convalescence. — The psychology of these convalescent patients is very interesting. As far as we know, very URINE 131 little has been done in regard to special study, but the most casual observer will note certain definite changes. Fortunately, these are only transient, lasting onh' a few days or a few weeks at most. Occasionally, abnormal emotional states may persist for long periods of time, but these are, perhaps, not due to the action of the virus of the disease but to the loss of power and consequent abnormal condition of the child, similar chronic conditions being met with in crippling from any cause. In the convalescing poliomyelitis patients some will be found to be normal and bright ; in others there is a very marked tendency to laugh or giggle or cry from very slight causes, or often for no reason at all. In others there is a continuous con- dition of irritability and fretfulness, the child cries a great deal and objects very seriously to being interfered with, even after the painful stage of the disease has disappeared. In still others there is a condition of sullenness or moroseness, as if the child had been made angr}' and had not gotten over it. The Blood.^ — The most complete studies on the blood have been made by Peabody, Draper and Dochez, in their monograph which was published by the Rockefeller Institute in 1912. The blood does not show anything characteristic, but merely suggests that there is an infection in the body. There is a constant and marked increase in the leukocytes, generally a polymorphonucleosis, and sometimes there is an increase in the lymphocytes. The increase in the total number of cells may be as high as 30,000. There is generally an increase in the polynuclears of from 10 to 15 per cent., and a diminu- tion of the lymphocytes of from 15 to 20 per cent. In one case a marked leukopenia was noted. The blood cells themselves present no abnormal pictures. The blood picture is so variable as not to afford any information of value as regards diagnosis. Hogue and Cepelka^ believe that the question of how long the child should be kept at rest before beginning massage and exercises may be solved by observing the white blood count. They suggest that manipulative procedures may be begun as the leukocAlosis disappears. This return to the normal varies in dift'erent patients, three or more weeks usually elapsing before the blood picture is what it was before the patient was taken with the disease. The Urine. — Retention of the urine may be noted and should always be looked for. In some cases it may be sufficient to require catheterization, but, as a rule, this does not last any great length of 1 Jour. Am. Med. Assn., August 26, 1916, p. 666. 132 SPECIAL FEATURES AND SYMPTOMS time. Sometimes there is only difficulty in starting the micturition, which is usually easily remedied by hot applications, by placing the child in a hot sitz bath or on a vessel partly filled with hot water. In comatose cases there may be incontinence, but this seems to be rather rare. The Glycosuria. — Peabody, Draper and Dochez have noted two instances in which the spinal fluid had an exceptionally high power to reduce Fehling's solution. One of these patients also had a glyco- suria, and it is possible that a lesion between the nuclei of the eighth and tenth nerve may have had the same effect as the " sugar punc- ture" of Claude Bernard, and so caused a hyperglycemia. The Respiratory Tract. — The respiratory symptoms with polio- myelitis are exceedingly variable in some cases; they may be very pronounced and in others absent entirely. There is not only a vari- ation in the individual cases, but in epidemics. For example, in the Hesse-Nassau epidemic in 1908 over 50 per cent, of the cases showed marked respiratory involvement. In some instances the disease comes on with coryza and a sore throat and some bronchitis, so that it may be mistaken for an attack of grippe. Often with this there may be a slight conjunctivitis which aids in making the error. In some instances there is bronchopneumonia, and, less often, a lobar pneumonia as a complication, and this is most apt to happen in cases in which there has been some involvement of the inter- costals or diaphragm. In some instances in which the respiratory muscles have been paralyzed the lung shows signs of pulmonary edema. It may be extremely difficult to tell whether one is dealing with a bronchopneumonia or a temporary effusion into the lung. If the patient lives the diagnosis usually becomes apparent after a day or two. The Heart. — The heart behaves in poliomyelitis very much as it does in any acute infectious disease. In addition to the various vasomotor phenomena that have been commented upon there may be disturbance of the rate or rhythm; in some instances there is no disturbance of the heart at all, in others a simple arrhythmia, in others a tachycardia or bradycardia, or there may be one of these latter together with disturbance of rhythm. Gastro-intestinal Tract. — A loss of appetite, nausea, and vomit- ing are all quite common. The vomiting is usually only once or twice, usually at the onset and after taking food. Sometimes, however, it may persist and be a very prominent symptom. The vomiting is not projectile as it is in meningitis. Sometimes the GASTRO-TNTESTINAL TRACT 133 older patients complain of gastric or abdominal distress, particu- larly after taking food, and there may be distention of the abdomen. Constipation is the rule, but it is just the same constipation, appar- ently, that is seen in any bed-ridden patient. Sometimes when there Fig. 47. — Patient with extensive bed-sore. Condition on admission to Children's Hospital School, Baltimore. About six months after onset. Patient, aged eight years. is involvement of the abdominal muscles one feels that the par- alysis may be partly responsible. In some cases there is diarrhea, but this does not seem to bear any relation whatever to the intestinal lesions as far as has been determined at autopsy. In some epi- FiG. 48. — Same as above. demies diarrhea may be a prominent feature. Thus Krause^ in an epidemic occiu-ring in Westphalia reported that over two-thirds of the cases had diarrhea. Deutsch. med. Wehnschr., 1909, p. 1822. 134 SPECIAL FEATURES AND SYMPTOMS Bed-sores. — ^The statement is made by the earlier writers that bed-sores are not met with, but one infers that they refer more particularly to the trophic disturbances so often seen in certain forms of spinal diseases. In the severely paralyzed cases bed- sores are not of uncommon occurrence and the greatest possible care should be taken to prevent them. The child should be kept scrupulously clean; patients that soil themselves are perhaps best treated by immobilizing them in plaster casts and placing them over a bed-pan. The skin should be washed several times a day with alcohol, and this should be applied after each cleansing and the skin powdered. In case the skin is reddened the application of zinc ointment or lanolin will be found of very considerable value. CHAPTER IX. THE TECHNIC OF LUISIBAR PUNCTURE. The Position of the Patient. — The patient may be either in a sit- ting posture, supported by a nurse, or he may be lying on the side. Everything else being equal, we prefer the latter position, inasmuch as syncope is less frequent and it is much easier to control the patient. The head and shoulders should be bent forward on the chest and the knees drawn up to the abdomen so that the spine will be bowed. It is a great mistake to attempt the lumbar puncture without sufficient assistance. Very young babies may be held by one nurse. For larger children two people are necessary, as it is very difficult to make the proper puncture unless the child is held perfectly still. Another person to hold the tubes in which the fluid is collected is advisable, though not necessary. A general anesthetic is seldom needed, although occasionally in very large, unmanageable patients this may be used. The puncture itself is not particularly painful, and is generally accomplished without accidents. It goes without saying that the strictest septic technic possible should be used. The hands of the operator should be sterilized and the needle thoroughly boiled. The preparation of the skin over the limibar region of the spine consists of thoroughly cleansing with alcohol, and after this is dry, applying a thin coat of tincture of iodin. The needle should be from 7 to 9 cm. long, ground with a rather blunt point and properly sharpened. The needle should be fitted with a steel obturator that fits perfectly, and this should be ground so as to be flush with the cutting edge of the needle. This is important, as otherwise a small piece of cartilage may be punched out and block the needle, and so result in a dry tap. The puncture is usually made between the third and fourth lumbar vertebme, sometimes between the second and third. A line through the superior parts of both iliac crests will pass through the fourth lumbar vertebra and the space just above the line is to be chosen. In adults and older children it is best to introduce the needle about 1 cm. to the side of the midline of the spine and direct the needle forward, upward, and slightly 136 THE TECHNIC OF LUMBAR PUNCTURE inward toward the midline. This avoids the strong interspinous Hgament. In children it is much easier to introduce the needle in the midline and point it slightly upward so as to pass between Fig. 49.— Lumbar puncture. (Musser.) the spines of the vertebrae. In the adult the needle is generally introduced for the distance of from 6 to 7 cm. before the sub- arachnoid space is reached. In children the distance, of course, is shorter and in infants the needle need only be introduced from 2 Fig. 50. — Lumljar puncture — introducing the trocar. (Musser.) to 3 cm. If in introducing the needle a resistance is met it is best to withdraw a short distance and introduce again in a slightly differ- ent direction, usually downward, as resistance generally means that PUNCTURE HEADACHE 137 the bone has been struck. After the needle has reached the spinal canal the obturator is withdrawn and the fluid allowed to run out. It may come drop by drop or be under considerable pressure and run in a rapid stream. The fluid should be collected in sterile test- tubes, and it is better to use two or three tubes in case one should be contaminated. If the fluid withdrawn is bloody it means the needle has punctured a small vein and another puncture should be done after resterilization, inasmuch as the presence of blood will interfere with the cell count. After the fluid has been withdrawn the needle is removed quickly and a piece of sterile gauze placed over the puncture and securely fastened with a strip of adhesive plaster. For diagnostic purposes 5 to 10 c.c. will be found sufli- cient. In cases in which the fluid is under great pressure larger amounts may be allowed to escape with a view of relieving sjonp- toms caused by increased pressure. When this is done the patient's pulse, respiration, and general condition should be closely watched and the withdrawal of the fluid stopped if there is any marked change for the worse. Puncture Headache.^ — ^This headache sometimes follows lumbar puncture, but is not serious and lasts but a short time. It usually does not come on until the day after the puncture at the time the patient is usually allowed to be up in case he is not afflicted with the disease. It may, however, come on immediately after the operation, or as long as three days later. It is a diffuse pain, felt on both sides and rather more severe over the forehead and some- what less so in the back of the head. Sometimes it is worse in the occipital region. There may be nausea and sometimes even violent vomiting, together with dizziness, some mental confusion and a feeling of faintness. Exercise increases the symptoms and lying flat down generally relieves it. The condition lasts, with remissions, from five or six days to two or three weeks. In the persistent cases the mental confusion and dizziness may cause alarm. Strauss states that if but a small amount is removed and that slowly, headache will not occur. The headache can usually be prevented by keep- ing the patient flat for three days or more, and if the headache does occur it is best treated by placing the patient flat on his back. A tight abdominal compress, which increases the amount of cerebro- spinal fluid, may also be used. Where abnormal conditions exist and there is headache from increased pressure, the withdrawal of fluid generally relieves it. 1 Dana: Jour. Am. Med. Assn., April 7, 1917, p. 1017. 138 THE TECHNIC OF LUMBAR PUNCTURE Normal Cerebrospinal Fluid. — Normal cerebrospinal fluid depends in amount to some extent on the degree of intracranial pressure, but, as a rule, about 5 to 10 c.c. are withdrawn during lumbar puncture. The fluid is clear and colorless, looks like water and drops from the needle drop by drop. The specific gravity is from 1.005 to 1.013, usually about 1.008. The reaction is alkaline and the fluid is found to contain water, albumin, fat, cholestrin, chlorides, sul- phates, phosphates, and alcoholic extracts. In addition to this there is present a small amount of urea and a trace of cholin. The sugar content of normal spinal fluid is present as glucose, from 0.06 to 0.09 per cent. Serum-albumin or serum-globulin and a trace of albumose bodies are also present. The freezing-point of normal spinal fluid is similar to the freezing-point of blood, about -0.56° C. Cytology. — A few endothelial cells may be seen and an occasional lymphocyte is present, otherwise no cells at all. Bacteriology. — As far as the presence of organisms are concerned, one can say with safety that in normal spinal fluid no organisms are present. Cell Counts of Cerebrospinal Fluid. — For diagnostic purposes both the number of cells present and the character are important. The Differential Count. — This is best made by pouring 2 or 3 c.c. of the spinal fluid into a conical test-tube and centrifugalizing for 40 to 50 minutes. The supernatant fluid is poured off and the sediment in the bottom of the tube taken up with a capillary pipet. By blowing the sediment gently back from the pipet into the test- tube several times, the cells are thoroughly mixed and a more accurate count can be made. A small drop of the sediment is then placed on a glass slide, spread out and allowed to dry in the air. It is then passed through the flame to fix it and stained. Wilson's, Jenner's, Giemsa's, or Hastings' stain may be used. Our own preference is for Wilson's stain, which after a little practice gives most satisfactory specimens. About 300 cells should be counted throughout the slide in order to arrive at a reliable estimate. Very expert laboratory workers may make the count with a low power. Those less expert will use a magnification of about 300, that is, about a number I eye-piece and a one-sixth objective. The Total Count. — This is made by exactly the same technic as is used in a total white count of the blood. The Fuchs-Rosenthal counter is generally preferred. A staining fluid is made up of methyl violet, 0.1; glacial acetic acid, 2; water, 50. A special THE CHEMICAL TESTS ' 139 counting chamber is designed for counting the cells of the spinal fluid. Using the white cell pipet the staining fluid is drawn to the mark I, the spinal fluid to mark XL All the cells in the entire ruled area are counted and the total number divided by 3 gives the number of cells per cubic millimeter. The Chemical Tests. — Tests may be made for globulin, albumin, and the reduction of Fehling's solution. The Glohulin Test. — Pandy's test will be found easy and reliable. The reagent consists of a saturated solution of phenol (carbolic acid), which is made by taking 100 parts of the pure crystals, and adding 100 parts of hot distilled water. This mixture should be kept at room temperature for a period of three or four days and during this time it should be shaken rather frequently. The clear supernatant fluid is then drawn off and is ready for use. In order to make the test 1 or more c.c. of the reagent is poured into the test-tube and one drop of the spinal fluid then added. Under normal conditions no change occurs when the spinal fluid is added. If, however, the protein content of the spinal fluid should be increased a bluish-white cloud is seen at the point of contact. This resembles somewhat a ring of smoke and after a short space of time settles to the bottom. The intensity of the reaction is judged by the density of this bluish- white cloud and varies directly with the amount of globulin present. This is usually recorded as with a cipher for negative reactions and by plus marks, varying from one to four, for positive reactions, according to the intensity. The Test for Albumin. — This may be made by the nitric acid test or by the heat and acetic acid test, or the total protein may be more accurately judged by the Kjeldahl method. The total protein may be approximately estimated by Tsuchiga's modification of Esbach's method. Tsuchiya's Modification. — ^The reagent consists of phosphotungstic acid, 1.5 grams, concentrated hydrochloric acid, 5 c.c, ethyl alcohol, 95 c.c. Special albuminometer tubes are employed which bear two marks, One U, indicating the point to which the urine must be added, and the other point R, the point to which the reagent is added. The lower portion of the tube up to U, bears a scale which reads from 1 to 7, corresponding to the amount of albumin per 1000. The tube is filled to U with the spinal fluid, the reagent then added to the point R. The tube is closed with a stopper, inverted twelve times, and then set aside for twenty-four hours. At the expiration of that time the amount per 1000 in grams can be read (milligrams). 140 THE TECH NIC OF LUMBAR PUNCTURE The Colloidal Gold Reaction and the Cerebrospinal Fluid.— After studying the cases in a small epidemic occurring in Baltimore in 1916, Felton and Maxcy,^ have given the results of their studies in reference to the reactions with Lange's colloidal gold test. This test was carried out according to the method advised by Miller, Brush, Hammers and Felton,^ whose article should be consulted by those unfamiliar with the reaction. They suggest that the different reactions be classified as occurring in zone 1 (paretic zone) , maximum precipitation from 1 to 10 to 1 to 160, with complete decolorization; zone 2 (luetic) , maximum precipitation from 1 to 40 to 1 to 160, with decolorization up to 4 (light blue); zone 3 (meningitic) , maximum precipitation beyond 1 to 160, producing a maximum decolorization of 3 (blue) . In the acute stage the fluid reacts in dilutions of from 1 to 40 and from 1 to 160. Later on in the disease, in the second and third weeks, the reaction either remains the same or there is a tendency to clear up in some cases, while in others there is precipi- tation in higher dilutions. During this period there is no constant rule. In the fourth to^ the eighth weeks the reaction runs prac- tically parallel to the globulin-albumin content and still occurs in dilutions of 1 to 40 and 1 to 160. The authors suggest that inas- much as the reactions occur constantly in the same zone that they may be of help in making a diagnosis in poliomyelitis. Macroscopic Appearance of the Cerebrospinal Fluid in Poliomyelitis. — Great care should be taken to avoid contamination of blood, and a No. 18 gauge needle, not over three inches long, will be found best suited for withdrawing the fluid for diagnostic purposes. If blood is withdrawn in the fluid it cannot be used for accurate diagnostic tests. If but little blood is present it will not cause any macroscopic changes, or if a slight amount is present produces a yellowish shimmer and an opalescence of the fluid. At the bedside the fluid is apparently clear in most cases, but if it is examined in a dark room with the test-tube illuminated by transmitted light, it will be seen to have a ground-glass appearance due to the increased number of lymphocytes. The use of a magnifying glass helps in this test, in some instances ; the particles in the fluid can be seen moving about and can be set in motion by slightly agitating the fluid. If the fluid is allowed to stand the cells sink to the bottom and the supernatant fluid is clear, but the ground-glass appearance can again be repro- duced by shaking. This appearance of the fluid often saves time in 1 Jour. Am. Med. Assn., March 10, 1917, p. 752. 2 Bull. Johns Hopkins Hosp., 1915, p. 391. CEREBROSPINAL FLUID IN POLIOMYELITIS 141 treatment of cases when serum is to be used, if meningitis can be excluded. The microscopic examination should always be under- taken later to avoid mistaking red blood cells for lymphocytes. Similar fluids may be found in cerebrospinal fever and other forms of meningitis. The Foam Test. — This is made by filling a test-tube half-full with the fluid and shaking very thoroughly. The presence of blood vitiates the test, which depends on the increased amount of albumin and globulin in the fluid in poliomyelitis. The shaking produces a foam which lasts from a half-hour to an hour or longer. It is much more dense and finer, and much greater in volume and more per- sistent than that produced by shaking a normal fluid. This is not supposed to take the place of the other tests, but helps in forming a judgment at the bedside before the fluid can be examined by the other methods. The Cerebrospinal Fluid in Poliomyelitis. — The cerebrospinal fluid in practically all, if not all, of the cases which show^ nervous S}Tnptoms, is abnormal, and may present a number of different changes, which, in the main, are constant. The fluid is sterile, usually clear, and sometimes a slight fibrin web forms in it. In exceptional cases the fluid may be cloudy or even bloody. Usually, the presence of blood means a faulty technic, the error generally being the use of a needle without a sufficiently close-fitting obturator. The number of cells is definitely increased. The normal fluid con- tains from five to ten cells per cubic millimeter, while in polio- myelitis the number of cells is increased from sixteen to twenty to one hundred, but in some instances this number is greatly exceeded, as high as five hundred or over being met with. In the early stage of the disease, before the paralysis has made its appearance, the chief t}T)e of cell found is the pohTnorphonuclear. Sometimes they form from SO to 90 per cent, of the cells present. After the appearance of the paralysis, the cells found are chiefly lymphocytes and from 75 to 100 per cent, of the cells present are that of the mononuclear type. There are also present large mononuclear cells of an endo- thelial type which have been regarded by DuBois and Xeal,^ as rather characteristic of poliomyelitis. There are also phagocytic cells present. It must be borne in mind that even a slight admixture of blood in the fluid will account for a certain number of polynuclear cells. The cells rapidly disappear from the cerebrospinal fluid, so ' American Journal of Diseases of Children, January, 1915. 142 THE TECHNIC OF LUMBAR PUNCTURE < Q < o Q Q P J EC o I— I <^ w W O «3 O H i3Q « H < '.■" c ■ffl ^^ o o 'S 3 6 _> 1s^ "5 03 03 oj c; oj -< O M M M -§ fl 1 _c * (U O Iz; iz; :z; H " ft '^ Ui 03 »:? 0) M 8 > if i » » + 3 + + + I =^ +•"•" 1 '^ + + + + 1 + + + .s + + + "3 "A -H 1 + + o 3 1 + + + 1 + + 1 + + ■H ■H + + + + + + + + + + + + + ^ 1 1 1 1 ^ + + + 1 + + 1 + + 1 a 1 Q) o „ M 03 1^ o o > o m «3 O 3 » oS f^.s-^ ft . 03 ft S >> O C £ o Is. s g- s .2 s. 03 " 9, 00 ^ ft § (U (D ftT3 O S O O P o > !> w Ph fin -ti o3 "u "^ 03 C! >> >i ft 03 B 5 03 03 3 T3 3 a < o ® ^ -43 qij ^ ^ o _o O o O o O O ^ o o Q o o o a o (^ (N IM o g'^ ^-t r-( ■-I S" 1 1 o i I o »c o <: 1-1 IM CO (N ■c TJ ■O t3 T3 £ ffl 0) 03 03 03 3 '3 a CA 03 03 m 03 oj 03 SS rt m 0) OJ 9 ? QJ ;h »H H Iri >H o o Cj u o Ph fl fl fl CI a hH (—1 h-t hH HH 1 A . o-B O CO a 8 '3 6 o CO a 'm .S 'a 03 a o '1 s . 2. a 03 a 43 CO 13 03 03 o CEREBROSPINAL FLUID IN POLIOMYELITIS 143 that after the first two weeks the count is either normal or nearly so. The fluid is sterile, gives a positive Fehling's reaction like the normal fluid, and usualh' contains a very definite reaction for globulin, which is, however, not as pronounced as that found in the various forms of meningitis. During the first week, globulin is found in perhaps one-half of the fluids examined. The globulin increases, as a rule, until about the third week, when it decreases, but a slight increase may be detected even after seven weeks or longer. The reaction to Fehling's solution is of slight value in diagnosis, inasmuch as in tuberculous meningitis, and sometimes in meningitis due to other organisms, this power to reduce Fehling's solution is absent. If the reaction is present it means nothing; if it is absent it is a point against poliomyelitis. We should also call attention to the fact that in certain cases of meningismus the fluid may be cloudy. These are cases in which there have been prolonged convulsions, cases of whooping-cough with very severe and frequent paroxysms, and fluids removed just before death. All of these fluids show an increase in the cells, and globulin or albumin is present, or both. In the case of convulsions the changes are probably due to the edema produced and in whoop- ing-cough they have been attributed to minute hemorrhages, whereas those coming on just before death are probably due to changes in the circulation. The fluid from sj^jhilitic meningitis may be hemorrhagic and in this case all of the successive tubes used to collect the fluid show the same appearance, whereas when a vein has been punctured the first tubes show more blood than the later ones. The fluid may be yellow and coagulate spontaneously and the so-called reaction of Froin, and this may also occur in other fluids. Chemical studies of fluids have yielded very little result. Various studies have been made by observers in New York on the total nitrogen, the amount of protein nitrogen, creatine and ammonia nitrogen, but information obtained by a study of these various constituents of fluid is very slight. CHAPTER X. DIAGNOSIS. The diagnosis of the disease presents certain difficulties, the commonest of which are in the cases seen in the preparalytic stage. If it is borne in mind that the disease is to be regarded as a general infection and that various parts of the body may be affected, one understands more readily the rather protean symptomatology of the disease. A careful study of the sjonptomatology of the pre- paralytic stage is important, and during an epidemic in all cases in which the disease is suspected a lumbar puncture should be made. The question of whether the child may have poliomyelitis with- out having any changes in the cerebrospinal fluid is, at present, an open one. The general rule is that if a case shows a normal spinal fluid it is not to be regarded as poliomyelitis. Usually where there have been any symptoms whatever of involvement of the nervous system the cerebrospinal fluid shows changes and the case turns out to be one of poliomyelitis. One sees cases occasionally associated with other cases in the same family, in which the cerebrospinal fluid is normal, but in which the patient is strongly suspected of having the disease. This point might possibly be cleared up by a series of observations upon animals. With the better understanding of the preparalytic stage and the cases which do not go on to paraly- sis, we feel sure that larger numbers of patients will be found who come under this class, and there is great need for some simple posi- tive means of differentiating poliomyelitis from other diseases. So far as we know skin tests have not been studied, but it would seem that this field might yield something of value. Immunity Test. — Another method of diagnosis which has been employed, but which is not suited for ordinary use, is to take the serum from the suspected patient, mix it with a fatal dose of the virus, and after incubating it inject it intracerebral] y into monkeys. Failure to develop the disease would indicate that the virus had been neutralized, but it must be borne in mind that serum from persons having had the disease might also neutralize the fluid, and if the individual had passed through an unrecognized abortive attack the results could well be misleading. Other Diagnostic Features. — Another feature in the diagnosis is to determine whether or not there is involvement of the nervous DIAGNOSIS 145 system, and all signs of meningeal irritation should be carefully studied. These have been considered in the symptomatology of the disease, and one should always study the intracranial pressure if the fontanelle is open, and also Brudzinski's leg and his head sign as well, Kernig's sign, and the others which it is not necessary to repeat at this place. Later the question of presence or absence of paralysis must be decided, and this at times, may be an exceedingly difficult point, particularly in young or very ill children. This has been considered in the section on Paralysis, to which the reader is referred; but we might call attention to one point which has not been decided, and that is the shortest length of time that the paralysis may exist in poliomyelitis. We are of the opinion that loss of power may be exceedingly transitory and may last only a day or two or three. The opinion of some other observers, however, is that the impahment of motion from poliomyelitis persists at least a week. No illness 96 Hysteria 2 Uremia and nepliritis 1 Tuberculous meningitis . 8 Rachitic pseudoparalysis Pulmonary tuberculosis Purulent pleurisy Tetany Gastro-enteritis and meuingismus Cerebral thrombosis Epilepsy and arthritis JNIentally defective (idiocy) Streptococcus meningitis Piu-ulent peritonitis Intussusception (?) ; gastro-enteritis Dentition Congenital calcaneovalgus Bronchopneumonia; pertussis Cervical adenitis and cellulitis Bronchopneumonia Diphtheritic paralysis Malnutrition and spasmopliilia Seven-5'ear-old case of infantile paralysis Pericarditis Kyphosis (Pott's disease) Cerebrospinal meningitis Hemiplegia and syphilitic endarteritis Transverse myelitis specific (?) Infiuenza meningitis Pneumococcus meningitis Cerebral arteriosclerosis with traumatic neuritis of supra-orbital nerve Spastic paralj"sis (congenital tetanoid pseudoparaplegia) Choi-ea Bell's palsy Septic arthritis Hemiplegia, cerebral hemorrhage Measles 10 146 DIAGNOSIS The Accuracy of Diagnosis. — ^As to the accuracy of diagnosis, the observers of the New York Health Department beheve that in private practice there are about 4 per cent, of errors made. In the cases which the department studied in the epidemic of 1916 the total error was 2.65. Some idea of what may be mistaken for polio- myelitis may be gained by a study of the accompanying list of diseases with which patients were found to be suffering after admission to the hospitals under the care of the New York City Health Department. All of these patients were primarily admitted as supposed poliomyelitis cases. Differential Diagnosis. — The following points will be found of interest in the differential diagnosis of the disease. These obser- vations might be extended very largely, but anyone with a clinical experience will find the points, given quite suJBEicient. One of the most important things at the outset is to exclude surgical things, such as sprains and fractures, and there are a num- ber of instances on record in which a child suddenly lost the use of an arm or leg and a diagnosis of poliomyelitis was made, and it was subsequently discovered that the loss of power was due to a fracture or a sprain. One should also remember that patients with other diseases, surgical or otherwise, may have poliomyelitis as a secondary infec- tion, and these cases may be exceedingly puzzling. We know of one instance in which a boy with a fractured arm was taken with very severe pains some two weeks after the injury, and it was sub- sequently found that he was suffering with acute poliomyelitis, and the pains had no relation whatever to the injury. Still another condition which may cause an incorrect diagnosis to be made is the loss of power which comes from pressure on a nerve. The pressure may not have been maintained long enough to produce an actual paralysis, and yet there is a definite loss of power from a few minutes to a few hours. Falling asleep with the arm over the side of a chair or over the side of the bed is the com- monest cause; one leg hanging over the edge of the bed, or the child's lying on some hard object and falling asleep may also occasionally be the history given in these cases. There is usually the sensation of numbness or tingling in addition if the child is old enough to describe its symptoms. In all cases in which there is a question about the loss of power the diagnosis should be withheld until the child can be seen on a subsequent day. This procedure will save many embarrassments. SCURVY 147 There are few diseases in which the physician may be so urgently pressed to say definitely whether the child is affected or not. Croup or Laryngitis. — With a paralysis of the laryngeal muscles the case may present such dyspnea as to require intubation and the child may be suspected of having croup, laryngitis, or laryngeal diphtheria. Other paralyses will generally be found on careful examination, and the absence of any other evidence of diphtheria will generally make the case clear. Bronchopneumonia. — A child with a paralysis of the respiratory muscles may suggest a pneiunonia. On careful examination either the thoracic muscles or the diaphragm will be found paralyzed. The fixed chest wall, either one or both sides with exaggerated abdominal breathing, characterizes the first. When the diaphragm is paralyzed, instead of inspiratory distention of the abdomen there is an inspiratory retraction. With hurried respiration and a little bronchitis or pulmonary edema the physical signs may be mis- leading unless one is unusually skilled. Nephritis with Uremia. — This may be misleading on account of the convulsions or coma. The edema and lu-inary findings will be sufficient to clear up the diagnosis, or a Imnbar puncture may be done. Acidosis. — Cyclic Vomitmg. — This may be very misleading. The profound languor may suggest a generalized slight loss of power, such as is sometimes seen. There may be twitching of the muscles and other nervous symptoms. The acetone odor of the breath and the marked diacetic reaction in the urine will point the way. The reaction in ordinary febrile distiu"bances is rarely as pronounced as in acidosis. A lumbar puncture may be needed. Diarrhea. — ^Mien the s^Tiiptoms of gastro-intestinal disturbances are very marked the diagnosis may not even be suspected, inas- much as meningismus and other nervous symptoms are not uncom- mon in connection with diarrhea. The lumbar puncture will afford a means of settling the question in suspected cases. A second class of disease in which there is pseudoparalysis or spasm may also cause difficulty in diagnosis. This includes scurvy, rickets, hysteria, the spasmophilia seen in nutritional disturbances, and tetany. Scurvy. — In severe scurvy the child assumes a position which suggests poliomyelitis. The paralysis is only apparent and the child can be made to move the extremities if sufficientlv irritated. 148 DIAGNOSIS In the very late cases the muscles will be seen to move if the limbs do not. The reflexes are normal. There are, in addition, the classic signs, the bleeding of the gums, the submucous and subdermal hemorrhages, the periosteal swellings, etc., and symptoms rapidly disappear on the administration of orange juice. Rickets. — In acute rickets there is a pseudoparalysis like that described in scurvy, but in place of the scorbutic symptoms there are marked evidences of rickets. Tetany. — The characteristic position, the spasm being chiefly in the hands and feet and bilateral, the exaggerated reflexes, the con- traction of the muscles on percussing the nerve, best seen in the facial, and the spasm caused by constricting a limb, make the diagnosis easy. Spasmophilia. — Apart from tetany a definite tendency to contrac- tion of the muscles exists in certain poorly nourished young infants. The reflexes are increased and the stiffness of the muscles is general. Hysteria. — This may present some real difficulties. Fortunately it is rare in older and practically absent in young children. The reflexes are normal and there are sensory disturbances, usually anesthesia of the glove and stocking type. If the condition has existed for some time the absence of marked atrophy is of value. The third class of cases includes those in which there is some definite disease of the nervous system. To avoid repetition let us insist wpon the necessity of obtaining the history of the attack. This will save many embarrassments and will also eliminate the congenital conditions. The history may be impossible or difficult to get or may be misleading, but usually it will help tremendously. In this connection one must bear in mind the possibility of encoun- tering an old poliomyelitis with some intercurrent fever added. We are dealing only with the diagnosis in the acute stage or near it, so that the differential diagnosis between the old nervous lesions will not be touched on. , In the following diseases the examination of the cerebrospinal fluid is the deciding point: Tuberculous Meningitis. — This may give more difficulty than any other condition. The general appearance, as a rule, is different, but this may not mean much until the child has been seen several times. The cerebrospinal fluid is under greater pressure than in poliomyelitis. Sooner or later there are changes in the eye-grounds. The onset is more slow and more irregular. The dominant symp- CEREBRAL THROMBOSIS 149 toms are drowsiness, vomiting, irregular pulse and respiration, con- vulsions, and rigidity of the muscles. The reflexes are increased. In poliomyelitis the length of time to reach the same stage is much more brief, and while in the preparalytic stage there may be rigidity or increased reflexes, the tendency is to become flaccid and to have a loss of reflexes. Cerebrospinal Fever. — kt the onset the two diseases may be strik- ingly alike. The sudden onset wdth vomiting and high fever, the prostration and rigidity of neck and extremities, the drowsiness with irritability and hyperesthesia, may be simulated by polio- myelitis. The petechial eruption, if present, is a help, and after a few days the marked spasticity and increased reflexes give a picture usually easy to distinguish. Acute Syphilitic Meningitis. — This may present considerable diffi- culties, inasmuch as the cerebrospinal fluids may be much alike. There is usually an optic neuritis, involvement of the extrinsic ocular nerves, and a little later there may be other paralyses, such as a hemiplegia. The onset is almost always gradual, usually tak- ing a month to six weeks to a full development, and during this time the patient is exceedingly nervous, subject to vertigo and sudden vomiting attacks without nausea and sometimes marked polyuria, occasionally convulsions and sometimes ataxia. In some instances the onset may be rather rapid, and in case of doubt a Wassermann should be made. Noguchi's butyric acid reaction may be of some value, as is also the colloidal gold reaction. Other Forms of Meningitis. — Much as above, the diagnosis depend- ing on finding the causal organisms in the cerebrospinal fluid. Meningismus. — Meningeal symptoms, drowsiness, retraction of the head, etc., may be seen in connection with inflammatory dis- eases of the body elsewhere, as in pneumonia and enterocolitis. This may be intensified by a great loss of fluid from the body, as in the last-named disease. These conditions may tax the diagnostic powers if only the symptoms and physical signs are depended upon. The recognition of the existing disease and the cerebrospinal fluid clear up any doubts. Cerebral Thrombosis. — This is seen in connection with inflamma- tory diseases elsewhere in the body^ and the diagnosis may not be suspected. If symptoms are produced that stand out above those of the causative condition they are convulsions and paralysis, eith.ir localized or general, strabismus and coma. When the disease extends from a neighboring inflammation, as in the nose or ear, the symp- 150 blAGNOBiS toms may be more marked, and consist of headache, drowsiness, and if pyemia occurs, chills, sweats, and a high variable temperature. We have seen one instance of a lateral sinus thrombosis in which the drowsiness and irritability were not unsuggestive of poliomye- litis. The localizing symptoms, cyanosis of the face with dilatation of the temporal and frontal veins in thrombosis of the longitudinal sinus, the marked edema of eyelids and face and protrusion of the eye in cavernous thrombosis, and the extension into the neck in lateral sinus trouble, soon make the diagnosis plain. Mental Deficiency. — When there is some febrile disturbance this has more than once been mistaken for poliomyelitis. The history, if obtainable, and the subsequent history, if not, will generally make the question clear, and one can always resort to a lumbar puncture. We have seen some extraordinary clinical pictures when the two were associated. Amaurotic Family Idiocy. — Tay-Sach's Disease. — This, too, can be mistaken if there is an intercurrent fever, as the flaccidity sug- gests poliomyelitis. The condition affects all the muscles, the blindness is apparent, and there are characteristic changes in the eye-grounds. It occurs in Jews, and the history of gradual onset, beginning between the third and sixth month, is usually obtainable. Transverse Myelitis. — ^This may occur in connection with the acute infectious diseases. The increased reflexes below the lesion and the involvement of bladder and bowels ought to make the diagnosis easy. Pott's Disease. — By pressure this may cause a paralysis with increased reflexes. The diagnosis is usually apparent, but cases have been sent to hospitals as poliomyelitis. Congenital Spastic Paralysis. — Despite the fact that these do not resemble acute poliomyelitis, they have been mistaken for it. The differential diagnosis of late poliomyelitis and these cases is another story. Chorea. — This disease has also been mistaken for poliomyelitis, but ordinary careful examination ought to solve the difficulty. Facial Paralysis. — BelVs Palsy. — In times of epidemic this may give considerable difficulty. In doubtful cases the only way to clear up the diagnosis is by lumbar puncture, but a facial paralysis coming on after definite exposure to cold and preceded by earache is apt to be called Bell's palsy, and the same is true of cases in which there is marked involvement of the ear. On the other hand. PERIPHERAL NEURITIS 151 a case coming on with a history simihir to poHomyelitis can fairly safely be classed as that disease. (See also Paralysis of the Seventh Nerve.) Peripheral Neuritis. — Cases of this disease may cause very dis- tinct difficulties in diagnosis. In children it usually follows an infectious disease. It is most common after diphtheria, and there Frontalis Corrug. S!(perci7.-4— ^^^i^^^j^.^ Orbicid. palpebrae-/^ t>>^ ®J Kasal^;^-' Zygomatic Majr—J* Minr- Orbiciilaris ovisac" Levator menti-- — A Quadrat- menti Triangular, menti- Platysni, viyoiqes* N. Phrenic I 1 point N".: Thoracic ant. g. Siemo-cleidoJ)>mstoid 6 ® N. Accessor Lus 7 • Trlipe'gmsS EEB'S ^^\ fj \® N,AxllJaris 9 ®JV. Thoracic long. 10 tPZca;. Brachial. 11 Fig. 51. — Chart showing the motor points for stimulating the muscles by the galvanic current: 1, contraction of the muscles of the forehead and the eyelids; 2, contraction of the muscles of the nose and upper lip; 3, contraction of the muscles of the whole half of the face; ^, closure of the jaws; 5, turning of the head to the opposite side; 6, turns face to the opposite side, the ear approaches the shoulder of the same side; 7, flexes head to the side, raises the shoulder, protrudes the lower jaw; 8, raises the shoulder and draws the scapula toward the spine; 9, contraction of the deltoid; 10, serratus action, scapula pushed forward and out; 11, contraction of almost all of the arm muscles. Erb's point: Get action on the biceps, deltoid, brachialis ant., and supinator long. (White and JelUffe.) is usually a history of throat involvement. The most common forms of paralysis are those of the soft palate and of the eye muscles, par- ticularly of the accommodation. The patient often shows irregular heart action, with dilatation of the heart. In poliomyelitis the paralysis comes on within a few days, usually within the first eight days. In diphtheritic paralysis the onset is later. In Rolleston's series, on which I commented in Progressive Medicine for March, 152 DIAGNOSIS 1914, the only forms of paralysis which occurred during the first two weeks were those involving the palate and the so-called cardiac paralysis. The ocular paralyses are more apt to occur during the fourth and fifth weeks, although some occur in the third week, and paralysis involving the lips, pharynx, or diaphragm almost always occur later than this, that is, during the sixth, seventh, and eighth weeks. In cases seen early a lumbar puncture will settle the ques- tion, but in cases occurring late in which no history can be obtained the difficulties of diagnosis may- be almost insurmountable. JExtetisian of the hand Supinator long. ExtenSi. carpi radihl* Extens. Ind Abduct, poll. Ion Extens. poll, brev, ( Ist.phalanx) Extension of hand and fingers ivith separation of :ihe latter and slight 1 flexion of two distal phalanges. • Emens. carp, ulnaris Extms. jpoT,l. long. (^ la^t phalanges) pduct. min. dig. Separation of the fingers and loith strong current fie.cion of the 1st. phalanges. Fig. 52. — Motor points for the muscles of the dorsal surface of the arm and hand. (White and Jelliffe.) Electricity in Diagnosis. — The electrical examination of nerves and muscles is one which requires a great deal of practice before satisfactory results can be obtained, and it is also necessary that the patient remain in a perfectly quiet state. With children this latter condition is difficult or impossible to obtain without an anes- ELECT RICirY IN DIAGNOSIS 153 thetic, and there are, perhaps, but few cases in which information of sufficient vahie could be obtained to warrant its use. No one who has not attempted to obtain electrical reactions in a child can realize the difficulty of the task. The two currents which are most extensively used are the interrupted or faradic and the con- tinuous or galvanic current. In order to test the reaction of the muscles it is important that both electrodes be in close contact Contraction of the flex. cavp. ulnar., flex dig. coinmun. prof., adduct. xjoll all muscles of hypotIi.enar eminence interossei and ord. and Uth. lumbrica Elex. carp, idnar • Flex.profund, ct^n^* Flex, dig, siibliiii.^p ii d' Hi Flexion of '{lie little finger contraction of interossei, ivth. lunib.^ \ x adduct. poll., and deep head of flex. poll, brev , Abduct. mfn.»dig. • flex. Opponensr} Flexion of 1st. phalanx and extens. of 2nd. and 3rd. •Del'tc Biceps' Contraction of flexors except flex, carpi ulnar, and flex. dig. achia^is int.. prof-- Contraction of thumb- muscles except adduct. poll, and id: ii lumtn-icales teres Supin. long carp.-rad. (flex, of the hand tcith ulnar rotat.) Flex dig. siiblim. Abduct, poll, ppponenspoll. ^Flex. brev. poll, uct. poll. Fig. 53. — Motor points for the muscles of the palmar surface of the arm and hand (White and JelHffe.) with the body, and if those tipped with sponge or leather are used they should be wet in salt solution first. It is best to place one electrode over the motor point of the muscle as described by Erb, and which are shown in the plates. The other electrode may be placed at some distance, so that the contraction of the one which is unimportant does not interfere with the reaction of the muscle which is being tested. The current should alwavs be tried on the 154 DIAGNOSIS operator before it is used on the patient, to be sure it is not too strong. The reaction of the muscles on the two sides — that is, of the sound side and the affected side — should be compared. The faradic current stimulates the muscle through the motor nerve, and it is important to have the electrode on the motor point. Reac- tions can be obtained at other places, but not so satisfactorily. In the reaction of degeneration, often referred to as R. D., the nerve Gluteus max. iatid nerve Flexion of the lower leg. BiscepsVf'mnrix • • Seniitendinosis (long head) \^ • jSemimeinbranosis (short he N. Peroneus Gastrocnemius (Ext. head) Soleus'-'i Flex, halluc.long. ITihiaTis;- flexion of the foot and toes astrocnemiiLS (Int. head) Salens Flex, commun. dig. long. N. Tibialis;- flexion of the toes. Fig. 54. — Motor points for the muscles of the posterior surface of the leg. (White and Jelliffe.) and muscle have undergone degeneration and the motor nerve has lost its power to conduct impulses from the cord to the muscles. In this case there is no response to the faradic current. In cases in which there is only partial degeneration the faradic current reaction will be found to be decreased, but not entirely absent. The galvanic current differs from the faradic in that it stimulates the motor-nerve fiber the moment of closing and opening the current. The nerve fiber is not stimulated during the time of flow. ELECTRICITY IN DIAGNOSIS 00 The muscle fibers are stimulated at the closing and opening of cur- rent, and also during the flow. If the nerve fiber is degenerated there will still be found a contraction of the muscle fiber if the galvanic current is applied. With this current the so-called polar reactions are made. The reactions at the time of closure and open- ing are a sharp contraction of the muscle, which remains in a condition of relaxation during the flow of the current. In normal Extension of the loicer leg. jV. Cruralis Contraction of the adductors N. Obturato) Adduct. mag. Additct. tonb. « Va;sius intern us * 'Tensor fascia laU iceps femoris • Rectuslfenioris • Vastus externus Fig. 55. — Motor points for the muscles of the anterior surface of the thigh. (.White and Jelliffe.) muscles the negative pole, also known as the kathode, gives a greater reaction at the closure of the current than the positive pole or anode. The reaction of degeneration shows that the muscle fibers will still respond, and even to a weaker current than they would under normal conditions. The change is in the reaction to the poles. The contraction to the anode or positive pole is now greater, or at least equal, to that of the kathode. Instead of the twitching 156 DIAGNOSIS motion of before, we have now a much more sluggish reaction. In the cases of degeneration there is present a slow reaction to the galvanic current, but the anode reaction is still greater than the kathode. Tibialis anfr— 1-* extens. commun. dig. long'. &\N. Peroneus;- extension of the ivhole foot tvith abduction. oPeroheus long. Salens Extens. halluf.'long. » Flex, hallucis long. I Interossei dorsalisi^'- tens.jcommim. dig.brev. Fig. 56. — Motor points for the muscles of the anterior surface of the leg. (White and Jelliffe.) The reactions are often expressed by letters, as kathodal closing contraction, K C C. The reactions of a healthy muscle as the cur- rent increases in strength isKCC >ACC>AOC >KOC, or this may be expressed : 1. Weak current K C C 2. Medium current KCCACC 3. Moderately strong current . . . KCC ACC AOC 4. Strong current KCCACCAOCKOC CHAPTER XL PROGNOSIS. The prognosis in poliomyelitis has to be considered from several standpoints: (1) during the acute attack there is the problem as to life itself; (2) as to the immediate paralysis and its extent; (3) as to the amount of paralysis that will be left; (4) as regards the recovery of the function and its relation to the earning of a living. As regards life, the problem is somewhat like that of any other acute infectious disease, but it has the difference that most of the deaths are due to involvement of the respiratory centers, a simul- taneous paralysis of the intercostals and the diaphragm being the usual cause of the fatal outcome, although some die from secondary reasons, such as the development of a pneumonia. The statistics available are based on the older conception of the disease and relate chiefly to the frankly paralyzed cases. The mortality rate varies in different epidemics from 10 to about 25 per cent. There are instances on record, however, in which the mortality was even very much higher than this. Wickman, for example, in a small epidemic of 26 cases, saw a mortality of 42.3 per cent. In 868 cases reported by Wickman the mortality was 16.7 per cent., which represents perhaps a good average. A low mortality and a high mortality may occur in the same year in different parts of the same country. For example, Zappert reported, in 1908, an epidemic in Northern Austria in which the mortality was 10.8 per cent., while Lindner and jNIally^ reported an epidemic in Eastern Austria occurring in the same year with a mortality of 22.5 per cent. The table on page 158 shows the comparison of some of the foreign and American death-rates, and is taken from the Massachusetts report of 1910: The younger children ha^ e a better chance for life than the older ones or adults. In Wickman's cases the mortality was 11.9 under eleven years of age and 27.6 between twelve and thirty-two years of age. ^ Deutsch Ztsclir. f. Nervenki-auk., xxxvi, 3-43. 158 PROGNOSIS Comparison of Foreign and American Death-rates. From THE Report of the Massachusetts Epidemic of 1910. Year. Cases. Deaths. Mortality per cent. Caverly, Vt 1894 • 132 18 14.5 Wickman, Sweden . 1905 868 145 16.7 Leegaard, Norway . 1905 577 84 14.5 Zappert, Austria 1908 266 29 10.8 Linder and Mally, Austria 1908 71 16 22.5 Fiirntratt, Steiermark . 1908 433 57 13.1 Krause, Germany . 1909 633 78 12.3 Miiller, Germany . 1909 100 16 16.0 Peiper, Germany 1909 51 6 11.7 Eichelberg, Germany . 1909 34 7 20.6 Massachusetts, U. S. A. 1907-1910 1599 125 7.9 Showing Higher Mortality in the More Advanced Ages. From the Report of the Massachusetts Epidemic of 1910. Wickman, Sweden . Leefraard, Norway ... Fiirntratt, Steiermark . Linder and Mally, Austria Massachusetts, 1910, U. S. A. Age, years. 12 to 32 15 to 30 Over 17 " 11 " 10 Per cent. 27.6 25.8 25.5 50.0 20.0 Mortality by Age (1909-10). From the Report of the Massachusetts Epidemic of 1910. Age, years. Cases. Deaths. Per cent. Under 1 82 10 12.19 1 to 10 945 59 6.24 Over 10 189 28 14.81 Totals 1216 97 Average mortality . . 7 . 90 Mortality by Age. Massachusetts Epidemic of 1910. Age, years. Cases. Under 1 38 1 to 10 451 Over 10 112 Total 601 Average mortality Deaths. Mortality per cent. 3 7.89 39 8.64 12 10.71 54 8.98 There is no way to tell which will be the fatal cases and which will recover, although with a certain amount of experience one can guess roughly at the ones that will probably terminate fatally. As death is very largely due to respiratory paralysis the MORTALITY BY AGE 159 involvement of the phrenic and intercostal centers is always watched for, but there is no way to tell whether a paralysis will extend or not. In the great majority of cases the lesions very rapidly attain their maximum extent and rarely advance after that. The involve- ment of centers near the vital ones does not necessarily mean that the disease will spread to that center, nor does the involvement of either the phrenic or intercostal centers alone mean a fatal prog- nosis. One occasionally sees cases recover in which there is paraly- sis of either the diaphragm or intercostals. The cases simulating Landry's paralysis of the ascending type are more apt to go on to the involvement of the respiratory centers than those which are struck suddenly without any tendency to extend. As a general thing the fatal cases are extremely ill during the first few days and cases that have extreme prostration at the onset are apt to terminate unfavorably. Cases high up in the cord are more apt to prove fatal than those in which the lesion is lower, and Peabody, Draper and Dochez found that all of their fatal cases had either paralysis of one or both deltoids, that is, the cervical cord was involved. Another point which they mention which we have been able to verify in a number of instances is that the patients who are profoundly ill and who have a very alert cerebration practically all die, whereas the cases which are in a stuporous condition are rarely fatal. One should not confuse the very irritable cases with alert cerebration, because the marked irritability is rather a favorable sign, if anything. Wickman found that death most often occurred on the fourth day of the paralysis, usually between the limits of from the third to the seventh day after the loss of power was noticed. If one counts from the beginning of the disease the deaths will usually come from between the fourth and the eighth day. After eight have elapsed the danger of death from the poliomyelitis itself is certainly very slight but not in all epidemics. The deaths which take place after this are apt to be from complications, particularly pneumonia. A pneumonia in connection with a respiratory paraly- sis is nearly always fatal, although not necessarily so. The treat- ment during the acute stage apparently has very little effect on the mortality. Whether the serum treatment in the future will affect this or not remains to be seen. The question as to whether paralysis will occur or not in a given case, and what its extent will be, is a very difficult one, and at the present time we do not believe there is any method by which this can be determined. The severity of the general symptoms bear 160 PROGNOSIS no relation to the occurrence of paralysis or to its extent. One may see cases with extremely severe general symptoms at the onset who recover promptly with little or no subsequent paralysis, and, on the other hand, one sees cases beginning mildly with a most widespread persistent loss of power. The extent of the paralysis or its occurrence bears no definite relation either to pain or to the reflexes. The reflexes may be lost and recur or be exaggerated and still there may be no definite paralysis. Draper suggests that the cases with a low cell count do not develop paralysis and those with high cell count usually do, although there are many excep- tions to both of these. After thirty-six hours from the onset the cell count and spinal fluid have little prognostic value. In fatal cases very high cell counts were seen within twelve to twenty-four hours of the onset. Deaths from Poliomyelitis by Day of Disease. Epidemic of 1916. New York Total deaths to August 31 Under investigation Total included in this study 1962 114 1848 Deaths on first day 55 " second day 179 " third day 315 " fourth day 369 fifth day 300 " sixth day . 182 " seventh day 110 Total for first week 1510 Deaths on eighth day . . 67 " ninth day 41 " tenth day 36 " eleventh day 28 " twefth day 16 " thirteenth day 15 " fourteenth day 8 Total in second week }11 Deaths on fifteenth day 11 " sixteenth day 15 " seventeenth day 8 eighteenth day nineteenth day 81 + per cent. 11+ per cent. 6 y 3 + per cent. 5 I " twentieth day 10 " twenty-first day 5 J Total in third week 60 After twenty-first day 67 3 + per cent. CONDITION OF PATIENTS AFTER RECOVERY 161 As to the question of whether a paralyzed muscle will regain its function or not — in a general way, the age of the child is very impor- tant and \ery young children are more apt to have a restoration of function than older children or adults. One natiu-ally wonders if this is due to it being easier to have nervous impulses sent along new routes in the young than it is after the child's nervous system has become more or less fixed. In a general way the severer the paralysis at the onset the more apt there is to be permanency of the loss of power, but there are many exceptions to this. The paralysis may occm* on any day of the disease, but after seven or eight days there is little or no danger of paralysis. In the great majority of cases the paralysis occiu-s on the first, second, thhd, or fourth day. There are some instances on record in which the paraly- sis has come on after eight days, even as long as eight weeks being recorded, but one rather doubts the real day of onset in these late paralytic cases. The prognosis as regards complete recovery and recovery of function seems to have varied greatly in different epidemics and in the experience of different observers. Perhaps the variations are due to the amount of care taken in making the after-studies. Wickman, in 530 cases, reports 56 per cent, as paralyzed and 4ri per cent, as cured. In the IMassachusetts report of 1910 there were 16.7 per cent, of complete recoveries. In the New York epidemic of 1916, 2715 cases discharged with paralysis were followed up, and of these, 1SS5 had a serious paralysis of one or both legs and were unable to work at the time of the report. There were 530 partly paralyzed in the legs, but able to walk, and 273 had one or both arms totally paralyzed. In foiu- hospitals under the New York Health Department, in which 3441 were treated, 716 died, or 16 per cent. In 1223 cases there was no visible paralysis on discharge, or 32.6 per cent, of total recoveries, and there were 2256 cases with visible paralysis, or 67.4 per cent. The average stay in the hospital per patient was 32.4 days. Condition of Patients after Recovery. ]\L^sachusetts Epidemic of 1910. Cases. Per cent. Complete recovery without atrophy 16 28.1 Functional recovery with atrophy 21 36.8 Recovery with some hypertrophy 3 5.3 Recovery, presence or absence of atrophy imknown .17 29.8 As regards the restoration of function, the problem is exceedingly difficult. In former days great stress was laid upon the value of 11 162 PROGNOSIS electric reactions, and the studies of Duchenne, of Boulogne, made many years ago, covers the ground satisfactorily as far as the gen- eral practitioner is concerned. He summarized the question as below: "Diminution of electric contractility from the first in direct proportion to the amount of damage done to the innervation of the paralyzed muscles, after a time return of electric contractility in these muscles or parts of muscles, the tissue of which is not changed." The whole question of electric reactions in poliomye- litis needs to be restudied by specialists. Very rapid and complete atrophy of a muscle or muscle group usually means the destruction of the corresponding nerve cells and the outlook for recovery of power is poor, but not hopeless, but there are some exceptions to this. The deltoid usually atrophies very quickly and completely. Lovett has suggested that in muscles which remain totally paralyzed to attempts at voluntary contraction at the end of three months, the outlook for any degree of recovery for marked function is not good, but he also added that the situation is not hopeless in these cases. In the very mild cases the paralysis may last but a short time, per- haps only a few days, although it seems that it usually remains at least seven to ten days. Ordinarily, if complete recovery is going to take place it does so within six weeks, although it may be delayed as much as six months. After this time complete restoration of function is very rare, although it may occur in the second half of the first year and in a very few cases even later than this. What generally happens is a partial recovery of the muscle power with a more or less complete restoration of function which may, on superficial observation, look like complete restoration. The prognosis as regards the restoration of function is very inti- mately connected with the proper treatment, and upon this too much stress cannot be laid. It means at the onset no meddling therapeutics; it means proper rest during the acute stage, with the use of whatever may be needed to prevent deformity. After the acute stage it means careful supervision until function is restored satisfactorily or for a period of at least two years or longer, during which time fatigue must be carefully guarded against. A great deal can be accomplished by means of massage and exercises, par- ticularly under trained supervision. The best results have been obtained where a nurse, expert in muscle training, has been employed. Lovett and Martin^ studied a certain number of cases 1 Am. Jour. Orthop. Surg., July, 1916. CONDITION OF PATIENTS AFTER RECOVERY 103 with reference to the effect of different forms of treatment, and they found that the chances for improvement with expert daily treat- ment were 6 to 1; with supervised home exercises, 3.5 to 1 ; whereas without supervision it was 2.8 to 1. They also studied 44 totally paralyzed muscle groups after the lapse of one year. In 48 per cent, of these after two months' training there was a certain amount of demonstrable power developed, whereas in a like number of cases of the same kind in which there was no treatment a return of power was noted in but 27 per cent. Another point in prognosis consists of the question of the danger of subsequent cord affections. The statement is often made that individuals who have suffered with poliomyelitis are more liable to organic nerve lesions later on. As to this there seems to be some question, inasmuch as comparatively few cases have been actually reported, and one must always allow for the possibility of coinci- dence. These individuals are probably more subject to functional nerve disturbances, particularly those who have extensive loss of power. Of the effects that have been described in association with old lesions are chronic muscular atrophy, progressive myopathy, and multiple sclerosis. Crouzon has described a man who had poliomyelitis in childhood, and between eighteen and forty years of age had nine different attacks of temporary hemiplegia. Pierre Marie has called attention to a form of sclerosis coming on about a decade after the acute attacks, which he called "scoliose tardive." Progressive muscular atrophy is another complication that has been reported a number of times. It was first noted by Raymond.^ Similar cases have also been described by Seeligmiiller and others. 1 Gaz. mcd., 1875, No. 17. CHAPTER XII. TREATMENT. For purposes of description we shall use the suggestion of Lovett and divide the disease into three stages: (1) the acute stage, from the onset to the diappearance of the tenderness; (2) the convales- cent stage, beginning with the disappearance of the tenderness through the period in which spontaneous improvement is marked, a period roughly estimated at about two years; (3) the chronic stage, when the condition has become more or less fixed, the extent of the paralysis more or less definitely determined, and any deformities definitely established. THE ACUTE STAGE. As soon as diagnosis is made, or even before if the child has fever, the child should be put to bed and kept there. In the more severe cases this is, of course, imperative, but in the very mild cases there may be a little difficulty experienced in getting the parents to understand the necessity of as near absolute rest as possible, and it may be hard to control the child. Efforts should, however, be made in this direction, as during the inflammatory stage any exer- cise and moving about must necessarily increase the amount of blood in the spinal cord and also causes action on the part of the motor cells which, from both theoretic and practical consider- tions, should be kept as much at rest as possible, so as to allow of the greatest amount of repair. In cases that are extensively par- alyzed it will be found a great advantage in the early stages to apply a plaster jacket and cast to the legs, a procedure which greatly facilitates the care of these patients, and if tenderness is present, certainly does much to lessen the suffering. The casts should be cut at the end of ten days to three weeks, and in such a manner as to allow the patient to be lifted out for purposes of bathing and also to allow a better circulation, and the patient may spend part of the time in the cast and part of it out, depending upon the condi- tion. During this acute stage, as long as tenderness is present, ACUTE STAGE 165 unless it lasts an undue length of time, it is best to omit any manipulation and also the use of massage or electricity. Pain and Tenderness. — These are best combated by absolute rest, by casts, by protecting the patient from the bedclothes with suitable frames, and by the application of heat. The affected part may be wrapped in flannel and heat supplied under the bedding frame by use of some of the electric devices or by hot- water bottles or the like, or by hot sand- or salt bags. Another thing which often gives great relief is to have the patient placed in a very warm bath, but this is, perhaps, as well not used during the first two weeks except in carefully selected cases. This is a very old form of treatment, and is mentioned by Badham. In some cases the pain may be so severe as to necessitate the use of anodynes. For this purpose, e^•e^ything else being equal, we have found a combination of codein sulphate and antipjTin to be of greatest service. It gives greater relief from pain than almost any combination of drugs that we have used, and is followed by less after-effects. The antipyrin may be omitted in case the general circulation is weak, or it may be replaced by an equal amount of sodium bromide. We generally prescribe ^ grain of codein with 1 grain of antipjTin for a child a year old, and this amount may be repeated at intervals of two hours, or in severe cases at intervals of an hoiu- until relief is obtained, or somewhat larger doses may be used if the smaller ones do not take effect. In older children a Ye, tV. h or I grain may be used in combination with from 2 to 4 grains of antipjTin. Syrup of orange makes a very excellent vehicle and is rarely objected to. Great care should be taken in very ill patients to prevent bed-sores ; the skin over the points of pressure should be bathed with alcohol two or three times a day and carefully powdered with talcum. In patients who have lost control of the sphincter there is usually also an extensive paralysis, and these cases are most easily handled by putting them up in casts and placing them in a frame over a bed-pan. Dyspnea and Respiratory Failure.— These may be treated by rais- ing the foot of the bed, if the patient's lungs are perfectly clear, by the administration of oxygen with an ordinary cone inhaler, or by the use of some form of pulmotor or lungmotor, either with or without the use of oxygen. In cases in which there has been a paralysis of the respiratory centers, when the heart is not involved, have been kept alive for mam' hom-s by use of artificial respiration and oxygen. In one instance Landolt kept a child alive for seventy- 166 TREATMENT two hours by this means, but the patient eventually died. In cases in which the lesion appears from above and spreads downward, Meltzer believes that the vasomotor center may be first involved and that death may be due to the rapid fall of blood-pressure. All of the cases with which we are familiar, and in which artificial respi- ration has been done, have died; but it seems perfectly possible that there may be cases in which, during the period of artificial respiration, the disease may cease to extend and recovery may take place. Cases with threatened respiratory involvement might be particularly suitable for the use of immune serum, or one might try the use of epinephrin, according to Meltzer's idea, which is given more fully elsewhere. Lumbar Puncture. — Great relief is afforded in many instances, particularly in the meningitic type, by relieving the intracranial pressure by lumbar puncture. When withdrawing the fluid is beneficial a lumbar puncture may be repeated at intervals, to be decided upon by the condition of the patient. The patient should be carefully watched while the fluid is being withdrawn and the procedure stopped at once in case of any untoward symptoms. (See section on Lumbar Puncture.) Use of Drugs. — As far as we know there are no drugs of any value in the treatment of the disease except the well-known remedies that are used for the relief of pain or to produce sleep, or as tonics, or for their special influence upon respiration, circulation, and the like. Codein and antipyrin are most suited for the relief of pain, iron and arsenic as tonics, and some of the bitter drugs, with small amounts of alcohol, for the loss of appetite, such as elixir of cinchona and elixir of calisaya. To stimulate respiration and circulation very quickly one may give aromatic spirits of ammonia by mouth or epi- nephrin hypodermically. When time is not such a big factor, but when prompt results are desired, 10 per cent, camphorated oil may be given. It should be injected directly into the muscles, either in the gluteal region or the outer side of the thigh. Less quick action may be obtained by using atropin. Digitalis is the best heart stimulant, either the fluidextract or tincture, by mouth, or what is known as Merck's digitalin, hypodermically. We are distinctly against indiscriminate drugging and do not believe that very much can be accomplished by the use of medicine except when given with the greatest amount of skill and judgment. Hexa- methylenamin has been suggested, but certainly has no value in the cure of the disease, although it may have some in its preven- ACUTE STAGE 167 tion. (See same.) Many drugs have been suggested, among others, quinine and urea hydrochloride. In the New York epidemic of 1916 the report of the Board of Health contains the records of 6 cases. Those under five years of age were given 5 grains intra- muscularly and then 3 grains by mouth every three hoiu-s. Children over five years of age were given 10 grains intramuscularly and 5 grains ever}' tlu-ee hours for twenty-four hours. They assume that the drug does not arrest severe cases, does not hasten recovery from paralysis, and does not absolutely prevent paralysis when given in the early stage, but it was thought that it might be of some benefit in the preparalytic stage. In this connection one should call attention to the fact that quinine has been recommended in rabies, which also affects the central nervous system, but it has been definitely proved to be of no value. Serum Therapy. — The basis for using a serum in this disease rests primarily on the fact that Flexner and Lewis, in 1910, demon- strated that monkeys that had had the disease and recovered could not be reinoculated. This was confirmed by other investigators. Subsequently, Romer and Joseph demonstrated that there are immune bodies in the blood of such monkeys which would neutralize the virus when mixed with it in a test-tube, and Levaditi and Xetter, and also Flexner and Lewis, showed that the same was true with the blood from human beings who had recovered from an attack. Flexner and Lewis after this demonstrated that monkeys which were actively immunized showed the presence of the same immune bodies. Flexner and Lewis then demonstrated that the serum from monkej^s or from individuals who had had the disease, injected into animals with the virus, even from eighteen to twenty-four hoiu-s afterward, and repeated during several days, would either inhibit development of the disease or limit its ravages if it devel- oped at all. The disease could be prevented by the subdural injec- tion of the serum, either after the injection of the virus into the blood or directly into the meninges. In the monkey the first symptoms of the disease are only from ten to twenty-four hours before the beginning of the paralysis, and this usually occurs from six to seven days after the inoculation. Fortunately, in man the disease does not develop quite as promptly, and the preparal^iiic stage is ordinarily from two to four days. The first observations on using this serum in man were made b}' Netter,^ Xetter and 1 Bull, de I'Acad. lued.. October 12, 1915. 168 TREATMENT Salanier/ and Netter.^ The serum was taken from individuals who had had paralysis, and even thirty years after an attack the immune bodies may still be demonstrated. When it was possible, however, they preferred cases in which the paralysis was of not more than five years' standing. The individuals were carefully examined and the blood controlled by a Wassermann reaction. The introduction of human serum into the spinal canal was generally very well toler- ated, but it causes an inflammatory reaction of the meninges, as is shown by specimens of the fluid drawn after subsequent puncture, the fluid at this time being cloudy and containing fibrin. The albuminuria is increased and the number of cells also increases, the polymorphonuclear cells predominating. Sometimes this fluid will produce a yellowish clot, and many times there are no symptoms of any change going on, but occasionafly there may be pain along the spine, with stiffness of the neck and body and slight elevation of temperature. Only twice in 32 cases was there any alarm caused by the injection of the serum. ■ Netter in his 32 cases had 6 rapid and complete cures, 3 cases so much improved as to approach a perfect cure, 7 were markedly benefited, and 5 appreciably so, but in these the influence of the serum was doubtful. In 3 cases the course of the disease was not modified, and 8 patients died, 7 from bulbar paralysis. Netter believes that the serum is capable of stopping the course* of the paralysis or even causing it to disappear if already started. He thinks that if it is given in the preparalytic stage it may prevent the occurrence of paralysis. The serum should be used within the first four days to be efficacious, as after that he does not expect any real benefit. In one instance they did inject the serum in the preparalytic stage, and there was no subsequent paralysis. Schwartz^ reports 21 cases in which he used a human convales- cent serum. Of these, 9 recovered without paralysis. In another series of 21 cases that were untreated, 17 recovered, the latter figures are the better. In the New York epidemic of 1916 a number of observers have used the serum. Amoss and Chesney^ studied 26 cases treated with human serum from recovered and convalescent cases. Twelve of the cases showed paralysis at the time the serum was first given, 1 patient died, 2 showed some exten- 1 Bull, et Tiiem. de la Soc. rned. deshop. de Paris, March 23, 1916, p. 299. ^ Arch, de mod. des enfants, January, 1916, p. 1. *Arch. Ped., November, 1916, xxxiii, 859. 4 Jour. Exper. AJed., April 1, 1917, xxv, 581. ACUTE STAGE 1G9 slon of the paralysis, while the remaining 9 showed no increase in the amount of paralysis. In 14 cases in which no paralysis was TEfiP. 104 103 102 101 100 99 3 4 5 ,6 1 6 ?l 1 1 1 \ r / 1 / \ / c / 1 ^ B 1 - ,/ V \/ ^ \, ^ V Fig. 57. — Temperature curve of a patient with poliomyelitis who developed a facial paralysis eighteen hours after the first dose of immune serum. This patient made a complete recovery. C, injection of 20 c.c. immune serum C; B, injection of 15 c.c. immune serum B. (Zingher, Journal of the American Medical Association, March 17, 1917, p. 820.) detected at the time the serum was administered, 2 died from respi- ratory failure, 2 others developed some degree of weakness or par- tial paralysis, and the remaining 10, or 71 per cent., did not show Fig. 58. — Typical curve in preparalytic case of poliomyelitis in which immune serum was given and which ended in complete recovery. B, injection of 15 c.c. immune serum B. (Zingher, Journal of the American Medical Association, March 7, 1907, p. 818.) any paralysis. They believe that the serum should be injected both intraspinally and into the general circulation, either directly 170 TREATMENT into the veins or into the subcutaneous tissue. In the hospitals under the New York Health Department a number of cases were treated, and they found that with a few cases three or four hours after the injection of the serum there was a sharp rise in the tem- perature, while in the other cases the temperature remained rela- tively the same for hours and then began to fall. In the progressive cases which resulted fatally the temperature continued to climb until death resulted. As a rule, after the injection there were more or less signs of meningeal irritation marked by stiffness of the head and back, general hyperesthesia, increased irritability, and, in the more severe cases, by stupor or delirium. In some cases the second dose was given twenty-four hours after the first, and in two cases the third dose was administered. The serum was used in 15 c.c. amounts and injected intraspinally. The condition was repeated when the general condition did not seem better, when the temper- ature remained up and there was still evidence of progressive involvement, and when there was no well-marked sign of menin- geal irritation after the first dose. The New York report goes on to state that the serum was used in a large number of cases with some beneficial result, but none of these gave sufficient evidence of cura- tive effect to adopt the use of such serum for the specific cure of the disease. In the cases that are paralyzed at the time the serum is given the results do not seem to justify its use, although we have, perhaps, not sufficient evidence at hand to be too dogmatic on this point. One thing is clearly brought to mind, and that is the neces- sity for very early diagnosis and the very early administration of the serum if it is to be used at all. There is at present, however, no way of telling how many cases seen in the preparalytic stage are going to be paralyzed, so it is that exceedingly difficult or impos- sible to estimate the favorable results obtained by using the serum. The whole subject needs much further study, and if the serum is used its preparation should only b«» undertaken by one skilled in laboratory technic and the administration by one thoroughly famil- iar with the lumbar puncture. In meningitis the lesion is more on the surface and the use of the serum does not tend to set up any irritation, but, on the other hand, the fluid clears on its use and the local condition is improved. In poliomyelitis there is usually an active increase in the cells, the exudate being composed of about 95 per cent, polynuclears and the number varying from 50 to 1000 per millimeter. The fluid at times is exceedingly turbid and seems almost purulent, but is sterile. ACUTE STAGE 171 Method of Preparing Serum. — The following is the method used by the workers of the New York Health Department during the epidemic of 1910, and the technic is taken from their report: To obtain the immune serum the blood is drawn from suitable donors in quantities varying with the age and the apparent hemo- globin content of the individual. On the average it is safe to with- draw 2 ounces from children nine to ten years of age, 3 or 4 ounces from children twelve to thirteen years of age, 4 to 6 ounces from individuals eighteen years of age and over. Adults, especially the robust, full-blooded kind, average 10 to 16 ounces of blood. Similar amounts can be withdrawn again after an interval of two or three weeks. The blood is best withdrawn by using a 15-gauge platinum or steel needle. In children and stout persons with small or indis- tinct veins a 17-gauge needle attached to a 1-ounce Record sjTinge may be satisfactory-. The blood is collected in small glass bottles in quantities of 1 or 2 ounces and given a long slant, so as to obtain as long a surface for the serum as possible. The blood is allowed to cool and the bottles are placed in the ice-box during the first twenty-four hours to allow the separation of the serum. This is decanted the following day and centrifugalized to free it from pieces of blood clot and red blood cells. To the serum is added 0.2 per cent, of trikresol. This increases the local irritant action of the serum, and it may be found advisable not to add it. The serum is then allowed to stay in the ice-box forty-eight hours, during which time there is a precipitation of a fine cloud that appears after the addition of the trikresol. After this is separated the serum is removed from it. The serum is then passed through a Berkefeld stone filter, bottled in quantities of 15 c.c. and kept cold in dark amber or blue bottles in the ice-box. Duration and Efficiency of the Servm. — If the serum has been preserved with trikresol or handled with sterile precautions after it has been passed through a Berkefeld filter and it is fterward kept in a cold place it will probably remain efficient in its specific content for several weeks. The serum obtained during the New York epidemic of 1916 was used up almost as fast as it was obtained. Some kept four to six weeks, however, seemed as active, therapeu- tically, as the more recently drawn. In an emergency, or when the facilities for treating with serum are not obtainable, blood may be simply drawn under aseptic conditions in a vessel with glass beads, shaken up and centrifugalized, or the serum may be drawn in the usual way and allowed to separate for a few hours and 172 TREATMENT promptly used, disregarding the presence of a few red blood cells. The serum probably owes its action (1) to the presence of specific immune bodies, and (2) to its action as normal human serum as such. The serum should not be heated. The donors should be free from syphilis, as demonstrated by a negative Wassermann reaction, and it should be definitely ascertained that the person has actu- ally had poliomyelitis and not a Bell's palsy or syphilitic paralysis, an ordinary hemiplegia, or tuberculosis of the joints. The length of time the immune bodies last in the body is a matter of conjecture. Flexner and Amoss^ report an instance in which they found the immune bodies on the sixth day of the disease, and they have been found years afterward. Netter is of the opinion that the most potent serum is found between three months and four years after an attack of the disease. Flexner and Amoss^ have shown that the cerebrospinal fluid taken very early and quite late exhibits no neutralizing action on poliomyelitic virus, and, indeed, the neutralizing principles have only been found very exceptionally in the cerebrospinal fluid. They have also shown that the immune bodies may be present in the blood as early as the sixth day of the disease and that the injec- tion of sterile horse serum into the meninges in monkeys increases their permeability, and this permits the immunity principles injected into the blood to pass into the cerebrospinal fluid. In monkeys that have been given injections of immune blood, the passage into the cerebrospinal fluid takes place during a rather short space of time, and apparently only while the inflammatory reaction pro- duced by the horse serum is at its height. Normal serum injected intraspinally into monkeys apparently does not exert any curative action. Inasmuch as the immunity principles appear in the blood only after several days the employment of normal horse serum, which seems, if it has any action, it is through increasing the per- meability of the meninges, permitting the escape of circulating immunity principles in the blood; but as these are not present during the first few days of the illness it would seem decidedly preferable to use an immune serum. Intravenous and Subcutaneous Injection.^ — The results where a combined intraspinal and intravenous injection has been made are somewhat more convincing than those based on the intraspinal injection alone. 1 Jour. Exper. Med., 1917, xxv, 499. ' 2 Ibid., April 1, 1917, p. 499. ' Amoss and Chesney: Jour. Exper. Med., 1917, xxv, 581. ACUTE STAGE 173 Draper suggests the use of a large intravenous or subcutaneous dose in cases before there are signs of involvement of the central nervous system and in which there is a negative spinal fluid where the child has been associated with another case. After ten or twelve hours a second puncture should be made and if changes are found then to use the serum intraspinally and another dose intravenously or subcutaneously. A?i Antiyoliomyelitis Horse Serum. — In 1910 Flexner^ attempted to produce an antipoliomyelitis horse serum, but after treating a single horse for many months did not find any immune bodies that had any restraining effect on the virus, either in vitro or within the body. We do not know of any other observations of this kind until Neustaedter and Banzhaf ^ reported the results of some obser- vations made in the Research Laboratory of the Department of Health of New York City. Any work done under Dr. William H. Park, director of the laboratory, is worthy of most careful consid- eration. It seems that the destructive action of the virus is prob- ably not due to an exotoxin but to the ability of the virus to multiply rapidly. They therefore thought it advisable to see if the horse would react to an endotoxin, and since Flexner obtained no results by using large amounts of the filtrates of the active virus, and exo- toxins and endotoxins cannot be produced by the Flexner and Noguchi methods of culture, the authors in question attempted to obtain an endotoxin by digesting the germ in the filtrate of a brain and cord emulsion of trypsin in 10 per cent, glycerin solution. The endotoxin could not be demonstrated, but at the end of August they started to prepare it, and early in September started to inject it into a horse. Five different injections were made, ending in November, and two weeks later the horse was bled and the serum prepared. Five neutralization experiments were made on monkeys, all of which were positive. On account of the scarcity of monkeys not as many observations were made as would otherwise have been done, but the authors feel that from their results they are justified in using the serum in human cases, especially if human serum is unobtainable. Following is the protocol of their first observation : Observation 1. — December 6, 1916, monkey 3 (mangabey) was injected intracerebrally with 0.5 c.c. of a 5 per cent, suspension of an eighth generation monkey virus, and at the same time 20 c.c. 1 Jour. Am. Med. Assn., September 24, 1910, p. 1112, 2 Ibid., May 26, 1917, p. 1531, 174 TREATMENT of the serum intramuscularly. Twenty-four hours afterward daily injections were begun of 3 c.c. of the serum intraspinally and 17 c.c. intramuscularly. These were given for seven days, when it was considered wise to cease treatment. The animal remained well up to December 17, four days after the last treatment, when it seemed ill at ease. December 18 the right extensor cruris was weak. On this day he received 3 c.c. of the serum intraspinally and 17 c.c. intramuscularly. December 19, he seemed to favor the left leg also. On this day and the following he received 3 c.c. of the serum intraspinally and 17 c.c. subcutaneously. The animal began to improve in the afternoon of December 19, and on January 7 was completely well and continues well today, four months after the inoculation. Control. — On the same day monkey 2 (Macacus rhesus) was injected intracerebrally with 0.5 c.c. of the same suspension of the same virus. This animal died in convulsions within six days and six hours. Histopathological lesions were characteristic of polio- myelitis. Normal Horse Serum and Normal Human Serum. — Various observers have suggested the use of either normal serum or normal horse serum by intraspinal injection. Some experiences with this method are detailed by Sophian.^ Both normal horse serum and normal human serum can easily be procured, and, if sterile and properly injected, are probably harmless. In order to avoid sensiti- zation to a foreign protein it seems preferable to use human serum. Horse serum when injected into the spinal canal seems to cause a hyperleukocytosis which he believes to be of very definite value. He used this method with horse serum on a series of 10 patients, mostly cases admitted late, and believes that in the few cases in which it was used early some definite improvement was noted^ The changes in the cerebrospinal fluid after the injection of the serum consist in a definite increase in the polynuclear cells and a very high cell count within eighteen hours, quite striking from the number of lymphocytes usually seen. Twenty-four hours after the injection the fluid becomes faintly opalescent, occasionally turbid, but examination shows a sterile fluid like that seen in aseptic menin- gitis. He also treated a small series of 10 cases with serum from convalescent patients, and in some he thought he obtained favorable results, but not better than in those cases in which normal horse serum was used. (See the Virus and the Choroid Plexus.) 1 Jour. Am. Med. Assn., August 5, 1916, p. 426. ACUTE STAGE < 175 Svv,vi(in/ of Serum Treatment.- — Immune serum, normal human serum, or sterile horse serum may be used. The exact value of these cannot be stated at the present time. AYe believe, howe\er, that one is justified in doubting both the efficacy or the advisability of the use of horse serum or of normal human serum. From the evidence at hand we do not believe that the immune serum, as used at present, "will be found to be of any value in the frankly paralyzed cases, certainly not unless used at the onset of the loss of power. In progressi^■e cases and those with threatened respiratory involve- ment the serum might be tried. In the preparalytic cases the results seem more encouraging, but until larger series of treated and non- treated cases are compared, it is impossible to say more at this time. If a definite diagnosis has been made and the serum is at hand, we ad\ise its use, but would not consider the failure to use it as a serious omission in the treatment. Antipoliomyelitic horse serum may be used in place of the human serum if available. (See same.) Autotherapy. — Duncan^ has suggested the use of the cerebro- spinal fluid withdrawn from the patient himself and injected into the tissues: 1 c.c. or less doses. We would not recommend this method of treatment at the present time. It has also been suggested that the blood be withdrawn from the patient's vein and the serum used intraspinally, a procedure which we deem of very doubtful value without having any definite information concerning it. Epinephrin or Adrenalin Treatment. — INIeltzer- has given an account of the use of this treatment with certain suggestions regarding its applications in human beings. He calls attention to the differences between the inflammatory focus and the inflammatory area in poliomyelitis, just as it may occur in other inflammatory diseases. He gives his experience with the use of artificial respiration in monkeys dying from the disease. In his studies he concluded that in cases in which there was an ascending paralysis death is due to a respiratory paralysis from an involvement of the centers of the chief respiratory nerves, while in cases of encephalitic poliomyelitis the vasomotor center may be the first to become paralyzed and death is due primarily to a rapid sinking of the blood-pressiu'e. As had been pointed out by Peabody, Draper and Dochez the three facts in the acute pathology of the disease consisted of a cellular exudate, hemorrhage, and edema, which may be regarded as the primary reaction of the nervous system to the virus of the disease, and from 1 New York iNIed. Jour., August 19, 1916, p. 342. = ihjd. 176 TREATMENT this come changes which result in part from direct pressure on the nerve cells. Without going into Meltzer's arguments more fully it may be said that he believes that if you can find a means by which edema and other processes occurring in the inflamed zone can be kept down, the nerve tissues so affected ought to derive a definite benefit. In the use of adrenalin we have an agent which, when applied to inflamed areas, will lessen congestion temporarily. Clark used this drug in some observations on monkeys, but only animals that were already extensively paralyzed or moribund when treated. Animals so treated seemed to show a very definite improvement for a time, although they eventually died. This method of treatment was used in over 70 cases at the New York Throat, Nose and Lung Hospital, and the results are given below. The technic of administration consists of injecting intraspinally 2 c.c. of a 1 to 1000 solution of adrenalin, and this is to be repeated every four to six hours. Before the first injection is given a fairly large quantity of spinal fluid should be withdrawn, the amount being in proportion to the pressure prevailing in the spinal canal. The subsequent injections should be made without regard to the presence or absence of spinal fluid, and unless the pressure appears to be very high, not much of the spinal fluid should be withdrawn, because at this stage the spinal fluid may contain some valuable antibodies. All injections should be washed in with 2 c.c. of normal salt solution, but if no spinal fluid is present at least 5 or 6 c.c. of salt solution should be used. In this connection^ he has a short note, in which he states that more than 50 babies received an intraspinal injection of a 1 to 1000 adrenalin chloride solution every six hours from the very beginning of the disease, that is, as soon as the patients were brought to the hospital. All of the patients stood the 2 c.c. of adrenalin intra- spinally for many days without the slightest harm. Lewis- has reported 77 cases in which adrenalin was used. He suggests getting rid of the 0.5 per cent, of chloret'one that is in the 1 to 1000 adrenalin solution by removing the stopper from the bottle and placing it in a bath of boiling water for two or three minutes. The solution is then allowed to cool, and he suggests that the injections be made without diluting the adrenalin with anything. A fresh preparation must be used at each administration. Eighteen of the patients died, but most of these cases were in children who 1 Jour. Am. Med. Assn., August 5, 1916, p. 461. 2 Med. Record, September 23, 1916, p. 541. CONVALESCENT STAGE 177 were moribund or who died from other conditions. Only o could be considered to ha\'e had a fair cliance under the treatment. Of those that recoxered 21 showed complete recovery, 21 were greatly improved, and at the time of the report it was supposed that more or less complete recovery would follow, and 17 showed disability that would probably be permanent. The results of its use in the New York epidemic were, on the whole, such as to lead the report of the Health Department to declare it without value. We believe, however, that the rapidly progressive cases and those with threat- ened or developed respiratory paralysis that it should be given a more extended trial. We do not advise its use in ordinarv cases. THE CONVALESCENT STAGE. This is usually reckoned from the end of the tenderness to the end of two years. During this period the child should be under observation and seen at sufficiently close interx-als to prevent the development of any deformity and to supervise the restoration of function. The question of when to get the child up out of bed is a very important one, and there are some differences of opinion. As soon as the pain and tenderness have disappeared the child should be gotten up as soon as possible. It will depend very largely on the extent of the paralysis how soon this will be feasible. From four to eight weeks are ordinary periods of complete rest in bed. After it is allowed up the child should never be allowed to fatigue itself, either locally or generally, and this is a point on which we have insisted in various places. Reasons for getting the child up are many. In the first place the normal child is a very active being, and nutrition is better and the child is healthier and happier and will develop mentally better if it is about; and it also permits a child being in the fresh air in many instances when it would not be possible otherwise. It has the additional advantage that the shorter time the child is kept at rest in bed the less trouble it will have in regaining its power to balance itself, all other things being equal. In the patients who are not able to walk or even stand the first care is to try to have the child propped up in bed so that he can sit up, care being taken, as far as it is humanly possible, to prevent deform- ities of the back, and, if necessary a properly fitting corset may be made to assist the weakened muscles. If the child is so paralyzed that he can neither walk nor stand alone it will be necessary to furnish sufficient amount of support by the use of braces. If neces- 12 178 TREATMENT sary, there may be a combination of properly fitting corset and braces used at the same time. Astonishing results can sometimes be obtained even in cases in which the outlook does not seem very favorable. Usually the first thing that is to be undertaken is to teach the child how to stand. With the added weight of the brace this may require some little time and patience. The child may be held under the arms or he may be supported by having a suitable frame to brace the body, or he may be stood up against a board and supported by a band under the arms. Gradually the new supports will become natural, and as soon as the standing is accomplished, with the aid of very little support, attempts may be made to teach the child how to balance himself. This is done by the use of crutches and whatever assistance may be necessary, or in some cases may be done by holding the child under the arms while he recovers the sense of equilibrium. This, in many instances, does not seem to be entirely associated with the loss of power, and in the rare ataxic cases may be an almost insuperable obstacle to teach the child to walk. As soon as the child can balance himself, walking may be taught, and in the slight cases this is usually accomplished very quickly, the child becoming accustomed to new conditions with remark- able ease. In cases in which both legs are very badly paralyzed, the child has to learn to walk with crutches, and this may be an exceedingly difficult undertaking. The mode of walking will depend largely on the extent of the paralysis. If possible, the child should be taught to move one foot forward after the other, using the crutches as an added support and balance. In the more severe cases this method will not suffice, and the child will have to be taught to support himself on the crutches and to advance them so that the body is now supported on three points, the legs at the rear and the crutches to either side forward. The legs may now be dragged up to where the crutches are and the crutches again extended. This is the most difficult part of the procedure and many times the little patients lose their balance and fall. This may be obviated to a certain extent by having one leg left somewhat behind the other so that the body will have three points of support when the attempt may be made to advance the crutches and then bring up the leg that is farthest behind. In the very bad cases the child will not be able to move the legs independently, but often will be able to get about surprisingly well by swinging the body on the crutches. Efforts should always be made, however, to teach the child to move the legs one after the other, and in many instances CONVALESCENT STAGE 179 by prolonged training the child may learn to walk, even with more or less complete paralysis of the legs, by twisting the pelvis from side to side, so moving one leg forward after the other. In considering hospital cases the method of procedure used by the hospitals under the New York Board of Health during the epidemic of 191G is interesting. After five weeks had elapsed the cases were studied with a view to what further treatment would be necessary. Out of 1707 cases the results of the treatment used when the patient was discharged from the hospital was as follows: In 6 cases the patients had extreme paralysis, were unable to hold the body erect, and there was no possible chance for ambulatory treat- ment. These cases were either given plaster supports and kept under observation or the hospital care was continued, the latter, of course, being the best method of procedure where it is possible. The second class of cases, consisting of 1443, had a slight paralysis or weakness, but there w-as evidence of rapidly returning power. These children were fitted with temporary plaster splints and kept under super- vision. The third class, consisting of 9 cases, showed no signs of returning power and were regarded as permanently paralyzed. These children were supplied with suitable braces and with crutches w^hen they were needed. The fourth class of cases, numbering 249, had a marked paralysis, but there were some signs of returning power, but it was very probable that recovery would take either months or one or two years. In these cases the patients were furnished with less expensive braces and those under one year of age were put up in suitable light plaster casts. Prevention of Deformity. — Of the utmost importance during the first few weeks is the prevention of contraction of the muscles with the consequent deformities. These often come on very early and can, in a very large majority, be prevented. The advantage of proper treatment is that the tendons and muscles are not allowed to stretch out of their normal positions. The commonest deformity is the foot-drop and toe-drop, but there may be contractions of the leg on the thigh and other deformities that are very apparent on examining the patient. INIany simple devices have been sug- gested, and it does not make very much difference what is used as long as it is found effective. The foot, for example, should be placed at the right angle to the leg and held in this position, either by a cast of plaster of Paris, which should be cut open at the end of a week or ten days enough to allow the proper care of the leg, or a right-angle splint made of wood or tin, or the deformity may be 180 TREATMENT overcome by the ingenuous application of adhesive plaster. Curva- ture of the spine is difHcult to manage in the early stage, but as far as possible, and consistent with the amount of pain and the irri- tability of the patient, attempts should be made to keep the patient in a position that prevents a deformity of the spine. This is very Fig. 59. — Paralysis of left arm and right leg. Shows a simple appliance for preventing foot-drop. much more easily said than done, and it may be necessary, on account of the tenderness, to do very little and use some other treatment to correct the condition later on. Fatigue. — It should be remembered that while a muscle may atrophy from non-use that it may also atrophy from too much use. This latter is well exemplified in the various atrophies due to occupa- CONVALESCENT STAGE 181 tlon, such as that seen in the hands of tailors. An atrophy from fatigue seems particuhirly Hable to happen when the nerves and muscles have been affected by poliomyelitis. Whoever is taking care of the child should be particularly warned to use the best possible care, and it is better to give too little exercise rather than too much, and the same is certainly true of both massage and electricity. Lovett has suggested the use of the spring-balance test, and if a muscle is getting worse instead of better in its capacity to work, as shown by the amount of pull that can be made, the treatments should be diminished to allow the muscles a greater amount of rest. Hydrotherapy. — ^This is of very great value and may be used for two different things. In the first place hot baths continued for ten to fifteen minutes or even half an hour, and, in some cases, even longer, may be used for the relief of persistent pain and tenderness, and in many cases has a most beneficial eflect. It may also be used as an aid in exercising muscles that are very weak. The child is placed in a warm bath, the weight of the limb in the water is very much less than it would be in the air, and the child can often move a paralyzed extremity in this way when it would be impossible to do so under ordinary conditions. After the acute stage is past the child may be placed in a warm bath every day and allowed to exercise the affected parts under careful supervision. Here, as else- where, great care should be taken to prevent fatigue. Under this heading the use of enemas for the prevention of constipation may be mentioned. Massage. — This is one of the most valuable means we have of treating the paralyzed cases, and it is to be highly recommended. The best results are obtained by trained operators, but a sufficient amount may easily be taught anyone of average intelligence. The advantage of massage is that it exercises the muscles and so directly stimulates nutrition, and also causes an increased flow of blood and lymph to the affected part and increases the flow of Ijniph and flow of blood away from the muscles, so carrying oft' the products of metabolism more rapidly than would be the case without it. It is of great service in overcoming the malnutrition and lack of growth of the paralyzed extremities, but too great results should not be expected of it in this connection. The manipulation should consist (1) of stroking movements and should, as far as possible, be from below upward so as to facilitate the Ij'mph flow, and then may be followed by kneading motions, the muscle or muscle group being 182 TREATMENT rolled between the thumb and fingers so that the muscle itself is manipulated and not merely the skin, and (2) the muscles may be gently patted, care being taken not to produce any pain or dis- comfort. It is very important that the treatment should not be continued too long and the manipulations should be much more gentle in younger children than that indicated in older children or adults. Overuse of massage brings about a lack of muscle tone and the overfatigue of the muscles probably helps to make it atrophy. Professional operators who have not had experience with children should be particularly cautioned on this point. The length of time for the treatment may vary with the age and condition of the child. With grown people recovered to reasonable robustness of health an hour may be taken to go over the entire body. Half this time should suffice for half-grown children, and younger children should be massaged from five to twenty minutes, always stopping if there is any sign of the child's getting irritated or showing fatigue. The massage may be combined with muscle training and exercise, and may often be given in a warm bath, which tends to increase the flow of blood and make the exercises much more easy. In using massage apart from the warm bath it is advisable to warm the affected part first by applications of hot towels (see Heat), and after the treatment the body should be carefully protected until the circulation has returned to normal. Mechanical vibrators may be used to great advantage, care being taken that the vibration is not too strong. It should not produce any unpleasant effects. Heat. — Heat may be used in connection with massage and a preliminary hot-air bath may be given, either to the whole body or to the affected part, preferably before using massage. The heated muscle acts more easily, the artificial taking the place, to a certain extent, of the warming-up process used by athletes, and it probably also acts by increasing the amount of blood flow to the heated part. If dry heat is used some of the simple forms of apparatus may be employed, and if expense is no object a suitable simple apparatus with electric-light bulbs with carbon filaments may be easily constructed, either big enough for the entire body or for one extremity. A simple method consists of using some of the electric heating pads, especially when the part that is to be warmed is not too large or the parts can be heated by applying hot wet towels. Moist heat cannot be used in as high temperature as dry heat, and in some people has a tendency to produce a tenderness of the skin. The heating process may be carried over from three to fifteen min- CONVALESCENT STAGE 183 utes and the temperature may be as high as the patient can stand without discomfort. The paralyzed extremities should always be kept warm by proper clothing and in cold climates and in winter, woolen underwear and stockings and gloves are to be recommended. If the child is unable to move about great care should be taken to see that it is kept properly warm, using artificial heat, such as a hot-water bag, should it be found necessary. Treatment by Electricity. — In former days electricity was used as almost the only means of treating the paralysis resulting from poliomyelitis. Often the patient was supplied with a small faradic battery and generally allowed to use it haphazard without much instruction. Personally, we have had but comparatively little experience, but we do not believe that electricity has a very high place in the therapy of poliomyelitis — at any rate, not as used at the present time. Careful obser\'ations by certain physicians, notably Lovett, seem to show pretty conclusively that electricity possesses no specific value. Electricity may be used to produce muscular contractions, even if voluntary exercise is impossible, and it may promote chemical changes in the muscles and so aid in muscle nutrition and growth. It seems, however, that in the main electricity does nothing that skilful massage will not do. One could readily imagine considerable harm being done by the indiscriminate use and overdosage in the hands of a mother or nurse who is under the impression that the battery contains some occult power. Either the galvanic or faradic current may be used. It is impor- tant that the confidence of the patient, especially if it is a young child, should be gained before any attempt is made to give electrical treatment, and it may be advisable to apply the electrodes for several days without passing any current through them in order to reassure the child. A very weak current may be used at the outset and gradually made stronger, and may be increased to the amount giving a good contraction of the muscles. If the faradic current is applied to a muscle that will contract to this current it is best to apply one of the electrodes at the motor point as described by Erb. If the muscle does not contract to this current there is no use in using it. The length of the treatment should be limited, not more than ten to fifteen minutes for going over an extensively paralyzed child, and only a few contractions for each particular muscle or muscle group. As a rule faradic current is not well borne by children, and it may be impossible to use it. In e^■ery instance the current should be passed through the operator's body before 184 TREATMENT trying it on the child. The faradic current may be used to contract the muscle best by placing the positive pole or anode over the muscle which one wishes to stimulate and the negative pole or kathode either a short distance away or over the spine. Each muscle may be contracted several times by opening and closing the current. Little or nothing is known about the effect of some of the newer forms of currents, and we have no information of any value regarding the high frequency, the Morton wave, or the sinusoidal current. CHAPTER XIII. ORTHOPEDIC TREATMENT. The fitting of braces to a paralyzed child is a matter that should be left to an orthopedic specialist when this is possible. The best results are only to be obtained by having the proper support pre- scribed by someone whose daily work gives him a clearer insight into the mechanical structure and possibilities of the many braces and splints used in orthopedic treatment. Wherever it is possible the child should be sent to one of the many excellent orthopedic institutions if the parents are unable to pay for expert care, or if the child is situated in a place where there is no competent ortho- pedic surgeon. A great deal of time and trouble will be saved by this method. There are no inherent difficulties in learning to prescribe the proper forms of support, but it takes someone with a somewhat mechanical turn of mind and a very thorough knowl- edge of what is desired to be accomplished. There are a very great number of different forms of splints and braces that have been designed for the various forms of paralysis and deformity. The brace may need subsequent adjustment and modification, and as the child grows or improves changes may be needed. A considerable damage may be done by one who is not familiar with the construc- tion of the various appliances and the use to which they are put. Braces and splints may be used for a great number of different purposes. Their chief uses are (a) support for weakened or paralyzed limbs; (b) to prevent deformity by maintaining parts above and below a joint in their proper relation to each other; (c) to prevent contracture of non-paralyzed muscles; (d) to prevent overstretch- ing of the partially paralyzed muscles. By preventing overstretching of paralyzed muscles and by holding affected limbs in the best possible position for the partially paralyzed muscles to functionate — they aid directly in the recovery from the paralysis. They are used to aid in the correction of existing deformi- ties in conjunction with other treatment. In other instances they may be applied as a matter of support to aid in the patient's walking and they are also used for the fixation of flail-joints. They also assist in maintaining the muscular balance and aid in lessening the 186 ORTHOPEDIC TREATMENT muscular strain and stretching of the group of muscles which are paralyzed. The simpler the splint is in construction the better it is apt to serve its purpose and it should be as light in weight as is con- sistent with the function that it is to perform. In children who are not going to need the aid of a brace but for a few months, one of inexpensive material and make is to be preferred. The same is true where there is any reason to believe that the brace is going to be changed in a comparatively shori time. In patients in whom the brace is to be a more or less permanent factor, or to be used for a long period of time a very much greater amount of care should be used in the workmanship and in the material, but in no case should the expense be considered to such an extent as to defeat the purposes for which the brace is intended. It must always be borne in mind that a splint or brace must fit the paralyzed member snugly, but it must not be too tight. Any sort of apparatus which interferes with the circulation or causes pressure in any way or which chafes the patient is apt to be rather a detriment than a benefit. The braces are usually made out of iron or steel bands or bars and are, in most instances, attached to the shoes when used for the lower extremities. In practically all cases the shoe forms a very important part of the apparatus and grf^at care should be taken in selecting a shoe that fits properly and is comfortable. The braces are supported above by additional bands or by straps with buckles. In the adjustment of the straps and bands it is very important that there is no undue pressure at any point and that they do not permit undue rubbing of the skin. The braces should be inspected from time to time to see that this is not taking place. If the appa- ratus is to be worn constantly it should be removed daily, where this is possible, to care for the skin. The chief use of braces is in the question of walking, for support and in the prevention of deformities and stretching of muscles. For other purposes and in most instances plaster casts are used. A splint very frequently is needed for the treatment of paralysis of the anterior thigh muscles and for this purpose either the caliper splint or the paralytic brace, is generally used. The nature of these braces is very well shown in the illustra- tions. The caliper splint is made of two iron or steel bars without joints running up the leg and thigh, one on either side to a padded ring which passes obliquely around the thigh at the level of the groin, the inner portion of the ring resting against the tuberosity of the ischium, and the outer portion a little above the greater trochanter. The lower ends of the uprights are turned inward at a SHORTENING 1joint. 9. " " " " ihac crests. ^ Figs. 62 and 63. — The Judson brace for paralysis of the quadriceps extensor muscle in connection with deformitj^ of the foot. (Whitman.) For Weak Limbs due to Partial Paralysis. — 1. Circumference in inches of ankle-joint. 2. 3. 4. 5. 6. 7. calf. knee-joint. thigh. pelvis just below iliac crests. ball of foot. instep. 8. Length in inches from sole of foot to ankle-joint. 9. " " " " knee-joint. 10. " " " " hip-joint. 11. " " " " iliac crests. 192 ORTHOPEDIC TREATMENT For Thomas Hip Splint. — 1. Circumference in inches of calf. 2. " " knee-joint. 3. " " lower third of thigh. 4. " " upper third of thigh. 5. " " crest of ilium (two inches below). 6. " " chest. 7. Length from spine of scapula one-third below middle of calf of leg taken posteriorly. Fig. 64. — A brace for complete par- alysis of the limb, showing a form of lock at the knee and a limited joint at the ankle. (Whitman.) Fig. 65. — Anterior poliomyelitis. Paralysis of the anterior and pos- terior muscles. Recurvation of the right knee. (Whitman.) MEASURING FOli ORTHOPEDIC APPARATUS 193 It is also a(lvisal)Ic to o})taln a drawing on paper of the limb to be fitted, which may be made with patient staiuh'ng and supported. It is important for the spine to be straight in order to get an accurate outhne. A lead strap which may be molded to the body and then used to make a tracing is a great help. Fig. 6G. — Brace for complete paralysis of the anterior muscles of the limb; before and after covering. (Whitman.) Fur Shoulder Brace. — 1. Circumference of body under axillae. 2. " " at waist. 3. " " between iliac crests and trochanter. 4. Distance in inches between lower border of both scapulae. 5. " " " upper border of both scapulse. With a piece of wire, mold exact form of spine from cervical ver- tebra (seventh) to sacrum (middle). Trace the shape on a piece of paper. 13 194 ORTHOPEDIC TREATMENT For Anterior Curvature of the Spine. — 1. Circumference of waist. 2. " body under axillae. 3. " pelvis between crests and trochanter. 4. " arm around shoulder and under axilla. 5. Length in inches from axilla to crest of ilium (both sides). 6. " " center of one scapula to other. With a piece of wire, mold shape of spine as spoken of before. For Lateral and Posterior Curvature of the Spine. — 1. Circumference of chest under axillae. 2. " pelvis between crests and trochanters. 3. Length in inches from axilla to crest of ilium (both sides). 4. Length in inches from center of one scapula to the other. 5.. Length in inches from sacrolumbar articulation to first vertebra involved. 6. Length in inches from sacrolumbar articulation to last vertebra involved. 7. Length in inches from sacrolumbar articulation to vertebral prominence. For Posterior Curvature with Cervical Involvement. 1. Circumference of top of head to chin. 2. " cranium. 3. " below iliac crests (one inch). CHAPTER XIV. OPERATIVE TREATMENT. All operations, whether they are done to correct a deformity or to improve the function of a part, should be undertaken only by one skilled and specially trained in orthopedic surgery. Operations undertaken by untrained surgeons are liable to be performed without a sufficiently correct diagnosis as to the lesion, and often without a very clear idea of what is going to result from any given procedure, and sometimes results may be obtained which militate very much against further operations of a helpful sort. At the present time there are a large number of excellent orthopedic hospitals and clinics at which the patients can easily secure attention or the surgeon special training. It should be borne in mind that no opera- tive procedure of any kind should be undertaken until at least two years have elapsed from the onset of the disease and not until after the patient is at least five years of age. The reason for this is that under proper treatment many very unusual things happen, par- ticularly in the very young, and an operation performed too early may be either unnecessary or will not be suited to the correction of the deformity or the improvement of function at a later date after the child has grown. The first consideration is the relief of the fixed deformity and, as a general rule, if the deformity admits of mechan- ical treatment, this should be tried first and very thoroughly and in many instances the operation may be avoided. There are, however, certain deformities which one realizes at the start can only be relieved by operative procedure. In many instances where there are con- tractions of the tendons and fascia relief may be obtained by stretch- ing the tissues and this should be thoroughly tried before any cutting is done. Fasciotomy or tenotomy alone will not often produce satisfactory permanent results. Taylor^ has given a brief account of the surgical treatment together with the more important biblio- graphic references. The Equinus Deformity. — This is the most common of all deform- ities and is due to the fact that the foot is allowed to drop and this 1 New York Med. Jour., January 29, 1916, p. 193. 196 OPERATIVE TREATMENT is increased by force of gravity aided by muscular contraction of non- paralyzed opposing muscles and often by the bedclothes pressing upon the toes. The foot being in constant plantar flexion allows the posterior muscles and tendons to contract, whereas those on the anterior part of the leg are stretched. This deformity may be very largely prevented in most cases by proper care of the foot, which should be undertaken from the beginning of the disease. After it has become established it may generally be relieved to greater or less extent by stretching. Lovett has described a method of treat- ment which will be found easy of application and to give very satis- factory results. This consists of putting the foot and leg up in a plaster-of-Paris bandage from the toes to just below the knee. The cast is applied while the leg is fully flexed on the thigh in order to relax the gastrocnemius and so permit of as much dorsal flexion as possible. After the cast has hardened for twenty-four hours an ellipse is cut out just in front of the ankle-joint and this ellipse should go two-thirds of the way around the cast at the point where it is cut. A strap of webbing is placed around the foot and another high up around the leg. These two are then joined together with another webbing strap fitted with a buckle. This may be arranged to pull either in eversion or inversion, as desired, and in this way a constant pull in the proper direction may be made. In the moderate grades a deformity may often be overcome in a week's time and in other cases two or three weeks or even longer may be necessary. In some cases it may be necessary to divide the tendo- Achilles and ordinarilya simple subcutaneous operation is performed. In other instances some of the more elaborate tendon-lengthening operations are preferred, such as Bayer's plastic tenotomy. Care should be taken in selecting cases on which tenotomy is performed, and if the anterior muscles of the leg are not in fairly gcod shape, after the plaster cast is removed an ankle brace with right-angle stop-catch joint should be worn to prevent recurrence. Some- times this is prevented by the use of an anterior silk ligament. In cases in which the quadriceps is affected, a patient often gets about better with the equinus deformity than if it is removed, and these cases should also receive very careful consideration before anything is undertaken. After the operation the foot and leg are put up in a plaster cast at right angle and the cast is usually left on about six week's time. Knee Deformities. — Flexion. — This is very often seen early, and efforts should be made to prevent its occurring. It may be HIP DEFORMITIES 197 the only deformity or associated with flexion of the hip and equinus deformity. The condition is best treated by putting the leg in a cast made fairly heavy over the knee and then cutting the cast for two-thirds of the circumference posteriorly just behind the knee-joint and gradually separating the cast by dri\'ing in thin wedges of wood. This permits of a gradual correction of the deform- ity, which, in mild cases, may be accomplished in a few days, whereas in the severer ones it may take many wrecks. The gradual reduction permits the stretching of the contracted tendons and muscles and even slight changes in the bones themselves. This method is far superior to the forcible reduction under an anesthetic, and in most cases can be accomplished without tenotomy of the hamstring tendons, but in exceptional cases this may be necessary. Osteotomy above the condyles in some of the extreme cases may be required, but this should not be undertaken until after the patient has become adolescent. Osteotomy is especially indicated in the older and severe grades of flexion deformity, in conjunction with tenotomy of the hamstring muscles, in order that the deformity may be corrected without too much stretching of the popliteal nerves, artery, and vein. In some of the severer cases of flexion of the knee, when the flexion deformity is overcome the child will be found to be knock-kneed. Hyperextension of the Knee. — This is usually not very extensive, but in neglected cases may reach the most astounding proportions. The condition is best treated by the use of a caliper splint with a posterior strap to prevent the hjyperextension and this should be used, if necessary, for the prevention of it. Knock-knees. — This deformity is not at all uncommon when there has been severe paralysis of the legs. It is, perhaps, best managed by use of a splint along the outer side of the leg with a leather band to pull the knee outward to the brace. In the worst cases osteotomy may be performed in the same manner as in cases caused by rickets. Hip Deformities. — ^There is usually more or less severe flexion of the hip, combined with abduction, and there is usually, though not always, flexion of the knee and plantar flexion of the foot as well. If the child is able to stand, the contraction causes a marked lordosis, and if it is unable to stand, the leg cannot be brought down on the table without causing extreme lordosis. Next to scoliosis this is the most difficult deformity to overcome. In cases in young children and those of not too long standing, stretching may be accomplished 198 OPERATIVE TREATMENT by placing the patient on a bed frame and then applying traction in the line of the deformity. In very young patients this method gives more or less satisfactory results, but in cases of long standing and in older patients it may require very long periods of treatment. A plaster jacket with a part to fit over the pelvis and a part over the thigh, joined together by a hinge and reinforced by means of a brace, may also be used and is said to give excellent results, but requires considerable technical knowledge to properly apply and requires very careful watching. Soutter^ has described an operation which has given very satis- factory results, and is far superior to the former myotomies, tenot- omies and fasciotomies, which were very severe and not altogether satisfactory. The Soutter operation consists of cutting down longitudinally between the anterior superior spine of the ilium and trochanter. This is followed by a division of the tensor fasciae femoris from the trochanter to the anterior superior spine and then separating the cartilaginous part of the spine and periosteum as far down as the anterior inferior spine. The patient is put up in plaster in a hyperextended position and kept at rest for six weeks. This operation permits a new attachment of the muscles and is the most satisfactory treatment yet devised. Abdominal Muscles. — Paralysis of the abdominal muscles, if severe, will cause a flexion of the lower part of the spine, so that the child walks with the abdomen protruded. These cases should be supplied with a properly fitting cloth or leather corset to obtain the necessary support. If the condition is of long standing it may be necessary to use plaster jackets in attempts to reduce it first. Tendon Transplantation. — Since Nicoladani first used this method in 1880 in poliomyelitis^ it has been a popular operation among orthopedic surgeons having to do with paralyzed children. The operation is one which is only to be undertaken after very careful study of the particular case in which it is to be used, for if this is not done the results will be far from satisfactory, particularly in the long run. It is particularly important to have a healthy muscle, capable of doing work that is to be expected of it, and, as a general rule, flexor muscles should be used for flexion and extensors for extension. While a certain amount of hypertrophy will take place in the muscle, enabling it to do increased work, this should not be too much relied on. The first operations were done by transplanting 1 Boston Med. and Surg. Jour., March 12, 1914, clxx. 2 Wiener med. Presse, 1881, p. 46. TENDON TRANSPLANTATION 199 the active tendon in the old tendon sheath and making the insertion into the tendon below. Neither one of these is very satisfactory, and in place of using old tendons the active tendon is transplanted in such a manner that the tendon will run in the exact line in which it is expected to work, and most operators now prefer to follow the method suggested by Lange, of inserting the tendon directly into the periosteum. When the tendons are not sufficiently long they may be lengthened by the use of silk, which eventually becomes covered with connective tissue and are converted into tendons. In some cases the tendon is passed through holes drilled into the bone at the site of insertion, which enables one to get a more certain and definite attachment. It should be borne in mind that before tendon transplantation is attempted, existing deformities should be removed to their fullest extent, otherwise the change and deformity may render the transplantation useless. The tendons may be passed subcutaneously and are usually drawn tight and the limb put up in an overcorrected position. Plaster is used for from five to six months or longer and a brace for at least a year more. After the cast is discarded the limb may be treated by massage and muscle training, but great care should be taken to wait until the transplanted tendon has become thoroughly settled in its new position before very much work is given to it. Tendon transplantation often gives most excellent results in the hands of skilful operators, but in many instances the correction is under what would be desired, and occasionally in an effort to avoid this the limit is overstepped and an overcorrection occurs. The most frequent and satisfactory deformity treated by this operation is the talipes equinus, in which the extensor of the great toe is inserted into the anterior part of the scaphoid. In talipes varus the peroneals are affected and the anterior tibial is transferred to the periosteum about the level of the mediotarsal joint, a little to the outside of the dorsum of the foot. In conjunction with the above operation, or separately, the outer half of the longitudinally split tendo-Achilles may be passed through and sutured to the peronei behind the external malleous. In talipes valgus, where the tibialis posticus is paralyzed, generally the peroneus longus is passed by a subcutaneous route behind the tibia of the inner side of the foot. Another method is to transplant the extensor longus hallucis or the peroneus tertius or both into the internal cuneiform bone at the insertion of the tibialis anticus. If both of these muscles are weak and the tendo-Achilles is strong, the tendo-Achilles may be split 200 ■ OPERATIVE TREATMENT longitudinally and the inner half transplanted into the tuberosity of the scaphoid bone at the insertion of the tibialis posticus. If necessary, a silk ligament may be used to lengthen it. This operation does not give very satisfactory results in talipes calcaneus. The best operation for calcaneus deformities, either simple or with valgus or varus, is Whitman's astragalectomy, described below. In quadriceps extensor paralysis the hamstrings may be trans- planted, provided the gastrocnemius is in good order, one or two of the tendons being extended with silk threads through an inser- tion in the tubercle of the tibia. Operations upon the arm by this method do not give as good results as those on the leg. Sometimes part of the pectoralis major, or better, the trapezius, is used in place of the paralyzed deltoid. Silk Ligaments. — This method, suggested by Herz^ and elaborated by Lange^ consists of using silk threads which, after being imbedded in the tissues a certain length of time, become covered with connec- tive tissue and so form ligaments. It is chiefly used in preventing foot-drop. Insertions into the periosteum were formerly used, but the results are not as good as when the silk is passed through holes drilled in the bones. The silk may break or the knots may come through the skin. The foot should be immobilized a long time. Several weeks in bed and a couple months ofi^ the feet. In careful patients the plaster may be replaced by a brace in six months, others should keep the cast on for at least a year. Tenodesis or Tendon Fixation. — Gallic^ has described this operation and its results in detail. It consists of converting the tendons passing over the ankle into ligaments by exposing them and then burying them in a groove in the bone after tightening sufficiently to overcome deformity. This is scarified and sewed in position and the foot immobilized in plaster for six weeks. Good results are obtained in carefully planned operations, but it permanently disables the muscles the tendons of which are used. Tendon Shortening. — This method of overcoming deformities has been tried by many different operators using various methods. Unfortunately, the muscle and tendon that has been stretched once will do so again unless the original cause of the stretching is removed, hence relapse almost invariably has followed. 1 Miinchen. med. Wchnschr., 1906, p. .51. 2 Ibid., 1907, p. 17. 3 Ann. Burg., March, 1913, and October, 1915; Jour. Orthop. Surg., .January, 1916. ARTHRODESIS 201 Astragalectomy. — This operation was suggested by Whitman.^ This is used chiefly in very bad cases in order to increase the sta})il- ity of the foot, and it has the advantage over arthrodesis in that it permits of a sHght degree of motion. Cases of paralysis of the gastrocnemius with resulting calcaneous deformities are particularly suitable for this operation, which consists of removing the astragalus and displacing the foot backward on the tibia, so that the malleoli grasp the front of the os calcis in place of the astragalus. The peronei muscles, if active, are transplanted into the os calcis at the insertion of the tendo- Achilles. The external ligaments are sutured and the leg placed up in plaster casts in the position of equi no valgus and three or more months allowed to elapse before any weight is borne upon it, or even longer time in case there is any doubt about the condition of the joint. A short plaster cast with cork under the heel or a brace that will hold the foot in the position of equinus is to be used when weight-bearing is begun. Later an extension shoe, with cork under the heel, will suffice to support the foot in the proper position. In many instances the results are very satisfactory, but in badly deformed feet there may be occasional cases in which the operation is not a success. Arthrodesis. — This is an operation in which the end-result is a stiff joint or an artificial ankylosis. The operation is usually done on the ankle, knee, hip, shoulder, or elbow, and consists in removing the cartilaginous ends of the joint and bringing the two surfaces of exposed bone together. This, under favorable conditions, does away with the joint, and while it results in some lameness and stift'ness some patients prefer this to the wearing of a brace. Each case should be very carefully studied before the operation is suggested or performed, and it is not a procedure to be undertaken except after mature deliberation, and it should be particularly remembered that it is not an operation to be used in young children. In the young the greater amount of cartilage interferes with their getting a stift' joint, and so much more may have to be removed it may interfere with the growth of the bone and extreme deformities may be pro- duced which render the patient much worse oft' then he was before. After the bones have attained their full growth or near it the opera- tion may ofter a certain amount of relief in carefully selected cases. Many different operations have been suggested, particularly to replace arthrodesis of the ankle-joint. An account of these will be found in Lovett's Treatment of Infantile Paralysis, p. 109. 1 Am. Jour. Med. Sc, November, 1902; Ann. Surg., February, 190S. 202 OPERATIVE TREATMENT Other Operations. — In certain selected cases other operative procedures are sometimes carried out. Knock-knees that resist ordinary treatment may be cured by an osteotomy, and this may be used sometimes in correcting other deformities. Resections of the joints is sometimes done, particularly in some of the more extreme deformities of very long standing. Nerve Transplantation. — This operation has received considerable study, but the results have probably not been anything like what would have been hoped from the operation. If the transplantations are made early, part of the result at least might have been obtained without transplantation, and if the operation is done late the changes in the nerves militates against the success of it. The largest number of operations have apparently been done by Spitzy and Stoeffel.^ They report 61 operations, and in 30 per cent, the results were good, in 40 per cent, the results regarded as not entirely satisfactory, and in the remaining 30 per cent, the results were bad. The most frequent operation is to use the obturator to the anterior crural in the hip or the peroneal nerve to the tibial, or vice versa} These operations do not give sufficiently good results to warrant their use in ordinary work. The Neurotization of Muscles. — Erlacher^ and Steindler^ found from observations on animals that it is possible to transfer a nerve directly into the muscle, and that eventually the nerve will form endings in the muscle with a certain amount of power. This opera- tion, after it is developed more fully, may be of some service in poliomyelitis in the future. Summary. — ^Lovett^ has given the following useful summary which shows his own preference for operation in the various deformities. It should be remembered, however, that there are many differences of opinion even among the most experienced operators, but this summary represents what one very successful orthopedic surgeon has found to be of value in his own experience. Talipes Equinus. — Stretching; tenotomy of the tendo-Achilles if the anterior muscles have fair power; transplantation of the extensor of the great toe or other extensors into the tarsal bones; anterior silk ligaments with or without tenotomy; tenodesis; arthrodesis. 1 Lange and Spitzy: Handbuch der Kinderheilk., Leipzig, 1910. 2 See also Osgood, Boston Med. Surg. Jour., June 30, 1910, and Zeiss, ibid., May 11, 1911. 3 Am. Jour. Orthop. Surg., 1915, xiii, 22. ^ Ibid., p. 33 6 Treatment of Infantile Paralysis, p. 121. SUMMARY 203 Talipes Calcaneus. — Astragalectomy ; tenodesis; arthrodesis. Talipes Varus. — Transplantation of tlie anterior tibial when that is active to the outer third of the foot; silk ligament from the fibula to the cuboid; astragalectomy; tenodesis; arthrodesis. Talipes Valgus. — Transplantation of one of the ])eroneals to the inner side of the foot; silk ligaments from the tibia to the inner side of the tarsus; astragalectomy; tenodesis or arthrodesis. Flexed Knee. — Stretching or open division of the hamstrings. Ilypere.rtended Knee. — In cases in which the quadriceps is par- alyzed and the hamstrings and gastrocnemius are good, transplanta- tion of one or two hamstrings into the tubercle of the tibia. Knock-knee. — Supracondyloid osteotomy (Soutter's operation). Flexed Hip. — Fasciotomy if severe. Dislocated Hip. — Arthrodesis. Shoulder. — Dropping of the arm away from the glenoid cavity; arthrodesis of the joint; silk ligaments. In cases of deltoid paralysis with the pectoralis major active the origin of the latter may be transplanted into the spine of the scapula. Operation in the forearm, elbow^, and ^^Tist cannot be summarized, as they vary greatly in individual cases. Arthrodesis of the elbow is useful, but the operation is not applicable at the wrist on account of the nature of the joint. CHAPTER XV. EXAMINATION OF MUSCLES AND MUSCLE TRAINING. It is very important in treating paralyzed cases to determine, as exactly as possible, what muscle or group of muscles is affected, and, having done this, to prescribe suitable exercises that will tend to strengthen the weakened muscles, and, as far as possible, train the nervous impulses to come from the brain through the spinal cord along new paths. It is advisable to make a record of the loss of power, not only the location, but the extent of it. The location is best charted on a figure of the body showing the various muscles, and the extent of it may be noted as complete or partial, or, better still, if the patient is in an institution equipped for it the extent may be noted by using Lovett and Martin's spring-balance test. It is very essential that the exercises be given to the mother or nurse, or whoever is to supervise the training, in a very exact way, and in most cases the movement used to determine the presence or absence of loss of power is the exercise used in the treatment. Fol- lowing the excellent set of exercises and tests formulated by Miss Wright and published in Lovett's book, we have worked out a set of tests and exercises, and have also noted the muscles and nerves involved and added illustrations to make the movements more clear. The patient should be taught to concentrate his mind on the movement that he is trying to make. The importance of this is noted by Barlow. The exercises should always be done under supervision and at word of command. The child or any other indi- vidual can scarcely carry out satisfactory exercises alone no matter how intelligent or well meaning. The patient should be told to make a certain exercise and then make it. If the attention flags, the exercise should be stopped for a few moments' rest and then should be started over again. Accuracy and precision of movement are especially to be aimed at, and while the tedium of doing the same thing over and over may be relieved, if possible, by making some sort of a game of the exercises, the importance of having the thing ordered done exactly must never be lost sight of. The exercises should be carried on with the operator and the patient in EXAMINATION OF MUSCLES AND MUSCLE TRAINING 205 a room alone, as outsiders detract the attention, and with some chikh'en it is difficult to get them to do things in the presence of a third person. It is important to remember that the patient should make a continuous movement when once he is started, and if the muscle is not strong enough for this the end of the movement should be aided by the operator, and this should be done in such a way as to have the movement actually continuous and not merely pick up after the patient has stopped. The exercises and movements that the patient can make most easily should be used first, and, as power returns, others may be added. As soon as the patient can make the movement completely without assistance, resistance may be gradually added by the operator ; but this should always be very slight at first and increased at a rate that is not too trying for the patient. Resistance should be greatest at the middle of the move- ment and weak both at the start and at the end. Exercises should be carried on six days in the week, and the seventh day may be taken for rest, which will prevent them from going stale. The exercises should be carried on rather slowly and sufficient time allowed between each movement to permit of complete recovery. Each exercise may be gone through with from one to ten times. If the patient does not do any movement as well as the preceding one he should be allowed a few moments' rest before going on. In every case it is of the utmost importance to avoid fatigue either of the muscles or of the attention. It should be remembered that young children and even older ones have their attention tired out very quickly, and if the child's interest begins to flag it is better to stop the exercise, divert it for a few moments, and then try again. The patient is best exercised on a flat, hard table rather than on a mattress or bed, which gives under the movements, and the best results are obtained when the patient is entirely undressed, which can always be done in the case of young children. Group of Muscles which Flex the Head on the Neck. Muscles. Nerves. Sternomastoid (chief). Spinal accessory. Omohyoid. Descendens and communicans. Sternohyoid. Descendens and communicans. Sternothyroid. Descendens and communicans. Mylohyoid. Branch of inferior dental. Rectus capitis anticus. First and second cervical. Longus colli. Lower cervical. Digastric. Mylohyoid branch of inferior dental and facial. 206 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Muscle Action. — Under normal conditions this group of muscles flexes the head on the neck — that is, brings the head forward. Test. — 1. In this test the patient may lie on the table flat on his back and attempt to raise the head from the table without raising the shoulders. Fig. 67. — Illustrating attempt to flex head with shoulders held down. 2. In this second test the patient sits down and allows the head to hang over backward and then tries to raise it forward in an attempt at flexion. Fig. 68. — Second step. Flexion completed, shoulders still held down. Exercises. — 1. The patient in this exercise is placed flat on his back and attempts flexion of the head by bending it forward. Care must be taken that the shoulders are not raised from the table. 2. The patient is seated in this exercise and attempts to bring the head forward from a backward or extended position. TEST 207 Group of Muscles which Extend the Head on the Neck. Muscles. Trapezius. Splenius capitis. Rectus capitis posticus. Obliquus capitis inferior. Semispinalis capitis. Nerves. Spinal accessory and cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Muscle Action. — Under normal conditions this group of muscles extends the head on the neck — that is, bends the head backward. Test. — The patient lies on the table face downward and attempts to raise the head. Exercise. — The patient assumes the same position as in the test, and the exercise consists in the attempt to raise the head from the table, without moving the shoulders. This may be done with and without resistance. Group of Muscles which Flex the Head Laterally. Muscles. Nerves. Sternomastoid. Splenius capitis. Longissimus capitis. Obliquus capitis superior. Rectus capitis lateralis. Semispinalis capitis. Spinal accessory and cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Posterior branch of cervical plexus. Muscle Action. — This group of muscles flexes the head laterally that is, bend it to one side or the other. Fig. 69. — Patient lying on unaffected side attempts to raise head laterally to side affected. Test. — The patient in this test lies on the side, which is unaf- fected, and attempts to raise the head laterally from the table or bed. 208 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Exercise. — The patient in this exercise assumes the same posi- tion as in the test and tries to flex the head of the suspected side without moving the body from the table. This may be done with and without resistance. Group of Muscles which Rotate the Head. Muscles, Sternomastoid. Splenius capitis. Longissimus capitis. Semispinalis capitis. Obliquus capitis inferior. Rectus capitis posterior major and minor. Nerves. Spinal accessory and cervical plexus. Cervical plexus. Cervical plexus. Cervical plexus. Cervical plexus. Cervical plexus. Muscle Action. — This group of muscles under normal conditions rotates the head to one side or the other. A turning movement. Test. — In this test the patient is seated and turns the head from one side to the other. Fig. 70. — Patient seated attempts rotation of head against resistance of examiner's hand. Exercise.— -In this exercise the patient is seated with the head turned toward the unaffected side and then attempts to rotate it toward the side on which the paralysis has taken place. This may be done with or without resistance. EXERCISES 209 Group of Muscles which Elevate the Shoulders. Muscles. Nerves. Trapezius. Cervical plexus. Levator anguli scapulae. Cervical plexus and posterior scapular. Rhomboids. Posterior scapular. Muscle Action. — Under normal conditions this group of muscles elevate the shoulders, that is, shrugs them. Test. — The patient is seated and shrugs the shoulders. Exercise. — Same. Group of Muscles which Flex the Humerus. Muscles. Nerves. Deltoid (anterior fibers). Circumflex. Pectoralis major. Anterior thoracic. Coracobrachialis (above the horizontal Musculocutaneous. line) . Serratus magnus. Posterior thoracic. Trapezius. Cervical plexus. Muscle Action. — Under normal conditions this group of muscles brings the humerus forward and flexes it in the horizontal line. This action is caused by the first group of muscles until the humerus approaches the horizontal line, when the serratus magnus and trape- zius begin to act, thereby fixing the scapula. Test. — 1. The patient lies face downward on the table or bed with the arm extended over the head and attempts to raise the arm without raising the body. 2. If the patient can stand or is able to be seated he attempts to raise the hiunerus to the horizontal line anteriorly. This test tries out all the muscles. 3. The patient is seated in this test and attempts to flex the humerus as in the preceding test. The examiner, in order to throw the action of the serratus magnus and trapezius out, presses firmly between the point of the shoulder and the neck of the patient. Exercises. — 1. With the patient lying on his face and the arms extended over the head, attempts are made to have the patient raise the arm from the bed without raising the body. 2. The patient m the seated or standing position attempts to raise the arm in horizontal flexion with and without resistance on the part of the examiner. 14 210 EXAMINATION OF MUSCLES AND MUSCLE TRAINING 3. The patient is seated and attempts to raise the humerus forward in flexion, while the examiner makes pressure as in the test described above. Fig. 71. — Attempt to flex humerus forward and upward against resistance. Group of Muscles which Extend the Humerus. Muscles. Neeves. Pectoralis majoi (sternal fibers). Latissimus dor si. Teres major. Teres minor. Infraspinatus. Triceps. Hyperextension. Latissimus dorsi. Teres major. Teres minor. Infraspinatus. Deltoid (posterior fibers). Anterior thoracic. Long subscapular. Lower subscapular. Circumflex. Suprascapular. Musculospiral. Long subscapular. Lower subscapular. Circumflex. Suprascapular. Circumflex. Muscle Action. — Under normal conditions this group of muscles extends the humerus — that is, brings the arm downward and for- ward — and the lower group (designated above) hyperextends the humerus, which means to carry the arm backward or back of the body. The scapula is fixed in this action by the pectoralis minor, trapezius, and rhomboids. TESTS 211 Tests. — 1. Tlie patient, either standing or sitting, with the 'arm raised abo^'e the head brings it down forward. This action is car- ried on until the arm comes in hne with the body. Fig. 72. — Patient seated, attempts to extend humerus by raising arm backward. Fig. 73. — With patient l^ing on face attempt to hyperextend humerus, resistance being offered. 2. The patient, either standing or sitting, with the arm at the side carries it backward as far as he is able. 3. The patient lies face downward on the table or bed and attempts to raise the arm backward. 212 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Exercises. — 1. If the patient is able to stand or be seated he attempts to bring the arm downward and forward from a position above his head. 2. The patient seated attempts to bring the arm backward from a position at the side. This may be done with and without resistance. 3. The patient lies face downward and attempts to hyperextend the arm by raising it backward. This may also be done with and without resistance. Group of Muscles which Abduct the Humerus. Muscles. Nerves. Deltoid (middle fibers). Circumflex. Supraspinatus. Suprascapular. Biceps. Musculocutaneous. Above the Horizontal Line. Serratus magnus. Posterior thoracic. Trapezius (acromial and inferior fibers) . Cervical plexus. Fig. 74.- -Attempt to raise humerus laterally (abduction) with shoulder girdle held firmly and resistance against humerus. Muscle Action. — Under normal conditions this group of muscles abducts the humerus — that is, raises the humerus to the side. The first group raises the arm above the horizontal line. The serratus and trapezius fix the scapula in this as they do in the other action of the shoulder girdle and the muscular groups. EXERCISES 213 Test. — 1. The patient, either standing or sitting, attempts to raise the arm sideways to the horizontal hne. In this test it is best to keep the palm downward, as the biceps is kept out of action in this way. 2. The patient assumes a position flat on the table or bed, either on his back or face, and attempts to raise the hmnerus from the side to shoulder height. The palm should be kept downward and the shoulder fixed by the hand of the examiner, as explained before. Should the patient be lying on his back the anterior fibers of the deltoid are brought into play, if on his face, the posterior fibers. It is possible for the anterior fibers to be paralyzed, and vice versa. Exercises. — 1. The patient, standing or sitting, with the arm at the side attempts to raise it from the side until it is above his head. The palm must be downward and the shoulder girdle fixed as in the test. This exercise may be tried with and without resistance. 2. The patient assumes the attitude of either l^ing on his back or face. The attempt is then made to raise the arm laterally from the side. In this exercise the examiner may offer resistance against the arm when the patient attempts to abduct it. Group of Muscles which Abduct the Humerus Horizontally. Muscles. Nehves. Deltoid (middle fibers) . Circumflex. Deltoid (posterior fibers). Circumflex. Latissimus dorsi. Long subscapvilar. Teres major. Lower subscapular. Teres minor. Circumflex. Infraspinatus. Suprascapular. Subscapularis. Short subscapular. Muscle Action. — Under normal conditions this group of muscles abduct the humerus horizontally — that is, carries the arm back at shoulder level. Test. — 1. The patient lies face do^^^lward on the table and attempts to raise the arms from the table. The position of the arms before the test is at right angle to the body and stretched out sideways. 2. The patient is seated facing the table with his arm in a posi- tion of adduction, by having it crossed over to the shoulder of the opposite side. In this position he attempts to abduct it. Exercises. — 1. The patient lies face do^siiward as in the test, with his arms at right angles to the bodv and stretched out later- 214 EXAMINATION OF MUSCLES AND MUSCLE TRAINING ally. He attempts as in the test to raise the arms from the table. This may be done with and without resistance. 2. The patient is seated with his arm in a position of extreme adduction by having it crossed over to the shoulder of the opposite side. In this exercise he attempts to abduct against the resistance of the examiner and without it. Group of Muscles which Adduct the Humerus. Muscles. _ Nerves. Pectoralis major. Anterior thoracic. Latissimus dorsi. Long subscapular. Teres major. Lower subscapular. Teres minor. Circumflex. Infraspinatus. Suprascapular. Subscapularis. Short subscapular. Deltoid (posterior fibers) . Circumflex. Muscle Action. — Under normal conditions this group of muscles brings the humerus to the side, that is, adducts it. Test. — 1. The patient, either standing or seated, brings the arm down to the side. 2. The patient lies on the table or bed, first on his back and then on his face. In either of these positions he tries to bring the humerus to the side of the body. If he lies on his back, the pectoralis major shows to better advantage; if on his face, the latissimus dorsi. Exercises. — 1. The patient, either seated or standing, attempts to bring the humerus to the side against the resistance of the examiner. 2. The patient, lying on the back or face downward, attempts to bring the arm to the side against the resistance of the examiner or without it. Group of Muscles which Adduct the Humerus Horizontally. Muscles. Nerves. Coracobrachialis. Musculocutaneous. Pectoralis major. Anterior thoracic. Deltoid (anterior fibers) . Circumflex. Muscle Action. — Under normal conditions this group of muscles adducts the humerus horizontally toward the middle line. This is done at shoulder level. MUSCLE ACTION 215 Tests. — 1. The patient lies on his back, and in this position, with the arms straight out at either side, pahns up, at shoulder level, brings the arms forward to the midline of the body until the palms meet above vertically. This test is chiefly for the pectoralis major. 2. The patient is seated against the table with the affected side supported at shoulder height and attempts to slide the arm forward. Exercises. — 1. The patient lies on his back with his arms at the side, straight out and palms up. In this position he brings the arms together by touching the palms vertically above his head. This may be done with and without resistance. 2. The patient does the exercise as described in the second test, that is, to rest the affected side on the table at shoulder level and draw the arm forward. The exercise may be tried with and without resistance. Group of Muscles which Rotate the Hutmerus Inward. Muscles. Nerves. Pectoralis major. Deltoid (anterior fibers). Teres major. Latissimus dorsi. Subscapularis. Anterior thoracic. Circumflex. Long subscapular. Long subscapular. Short subscapular. Fig. 75. — Attempt to rotate humerus inward, resistance against ulnar side of wrist. Muscle Action. — Under normal conditions this group of muscles rotates or twists the himierus inward. 216 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Geoup of Muscles which Rotate the Humerus Outward. Muscles. Nerves. Deltoid (posterior fibers). Infraspinatus. Teres minor. Circumflex. Suprascapular. Circumflex. Muscle Action. — Under normal conditions this group of muscles rotates the humerus outward. Tests. — (The tests and the exercises are alike for inward and outward rotation, that is, the positions are the same, and the only difference lies in the twisting, therefore they are both given below under one heading.) Fig. 7C. — Attempt to rotate humerus outward, resistance against radial side of wrist. 1. The patient lies on his abdomen face downward, with the arm stretched out sideways at shoulder height. The forearm and hand hang over the table, so that the former is bent at right angles to the arm. The examiner steadies the upper arm while the patient attempts to raise the hand backward and upward in an attempt at rotation. When the patient raises the hand forward and upward he attempts outward rotation. 2. The patient lies on his back with the arms close at the side and the elbows bent at right angles. The forearm rests across the chest. He then attempts to turn the arm outward and inward, pivoting it on the elbow. EXERCISES 217 Exercises. — 1. The patient assumes the position as described in the test by lying face downward and his arm stretched out side- ways. The forearm and hand hang over the side. He attempts to rotate the arm outward by bringing the hand forward and upward with the examiner ofl'ering resistance against the radial side of the wrist. The examiner then offers resistance against the ulnar side of the wrist, while the patient attempts to raise the hand backward and upward for inward rotation. The arm must be held by the examiner. 2. The patient lies on his back with the arms at the side and pivoted on the elbows, which are at right angles to the arm, and, as described in the test, attempts inward and outward rotation by turning the forearm outward at first and then bringing it back. Group of Muscles which Flex the Forearm. Muscles. Nerves. Biceps Brachialis Supinator longus Pronator radii teres Flexor carpi radialis Flexor carpi ulnaris Palmaris longus Flexor digitorum sublimus Flexor digitorum profundus Lumbricales Interossei Flexor brevis minimi digiti Extensor carpi radialis. Extensor carpi ulnaris Extensor communis digitorum Extensor longus pollicis Musculocutaneous- Musculospiral. Musculospiral. Median. Median. Ulnar. Median. Median. Anterior interosseous and ulnar. Ulnar and median. Ulnar. _ Ulnar. Musculospiral. Extensors of wrist and fingers in pro- } Posterior interosseous, nation Flexors of wrist Flexors of fingers Note. — Biceps is a flexor supinator. Pronator teres is a flexor pronator. Muscle Action. — Under normal conditions this group of muscles flexes the forearm on the upper arm — that is, bends the elbow. Tests. — 1. The patient is seated and bends the elbow until the hand touches the shoulder; this should be tried both in pronation and supination in order to test out all the muscles. 2. The patient lies on the affected side and bends the elbow until the hand touches the shoulder. Exercises. — 1. The patient is seated and bends the elbow to the shoulder until the hand touches, both in pronation and supination, with and without resistance. 218 EXAMINATION OF MUSCLES AND MUSCLE TRAINING 2. The patient lies on his back with the upper arm supported vertically and flexes the forearm with and without resistance. Fig. 77. — Patient attempts to flex forearm. Resistance offered by examiner. Group of Muscles which Extend the Forearm. MtrscLES. Triceps. Anconeus. Extensor carpi radialis Extensor carpi ulnaris Extensor communis digitorum Extensor longus pollicis Extensor indicis proprius Extensor minimi digiti Lumbricals Interossei Nerves. Musculospiral. Musculospiral. Extensors of wrist > Posterior interosseous. Extensors of fingers in supination Posterior interosseous. Median and ulnar. Ulnar. Muscle Action.^ — Under normal conditions this group of muscles extends the forearm — ^that is, straightens the elbow. Tests, — 1 . The patient is seated with the upper arm raised above the shoulder and supported, with the elbow flexed. He then attempts to extend the forearm. 2. The patient lies on the afi^ected side with the elbow flexed and attempts to straighten it. Exercises. — 1. The patient lies on his back with the upper arm in a vertical position and elbow flexed and then attempts to straighten it with and without resistance. MUSCLE ACTION 219 2. The patient is seated witli tlie forearm flexed and attempts to extend it. This mav also be done \vith and without resistance. Fig. 78. — Patient seated with forearm in flexion attempts extension. Resistance offered against ■wrist bj' examiner. Group of Muscles t\tiich Supinate the Forearm .vxd Hand. Muscles. Supinator radii bre\'is. Supinator radii longus. Biceps. Xerves. Posterior interosseous. Musculospiral. Musculocutaneous. Fig. 79. — Forearm on lap with hand palm down. Position in which supination is attempted. Muscle Action. — Under normal conditions this group of muscles supinate the forearm and hand — that is. tiu'n the palm upward. 220 EXAMINATION OF^MVSCLES AND^MUSCLE TRAINING Test. — The patient is seated with the forearm in his lap and the palm tm-ned down and then attempts to turn the palm upward. Exercise. — The patient is seated as in the test and with the palm turned down; he attempts to supinate the forearm by turning the palm upward. Group of Muscles which Pronate the Forearm and Hand. Muscles. Pronator radii teres. Pronator quadratus. Flexor carpi radialis. Neeves. Median. Anterior interosseous. Median. Muscle Action. — Under normal conditions this group of muscles pronate the forearm and hand, that is, turn the palm downward. Test. — ^The patient is seated with the forearm resting in his lap and the palm turned up, and then attempts to turn the palm down. The examiner may grasp the hand and resist this movement. Fig. so. — Forearm on lap with palm up. Position in which pronation is attempted. Exercise. — The patient is seated as in the test and attempts to turn the palm downward with the examiner resisting by grasping the hand. EXERCISES 221 Group of Muscles which Flex the Wrist. Muscles. Nerves. Flexor carpi radialis. Flexor carpi ulnariis. Palmaris longus. Flexor sublimis cligitorum. Flexor profundus digitoruni. Flexor longus pollicis. Median. Ulnar. Median. Median. Anterior interosseous and ulnar. Anterior interosseous and ulnar. Muscle Action. — Under normal conditions this group of muscles flexes the wrist — that is, draws the hand downward. In case of paralysis, extension of the wrist is present. Tests. — 1. The patient places the forearm on the table with the hand extended over the edge and the palm upward. In this posi- tion he tries to flex the wrist. 2. The patient places the arm on the table with the ulnar side down and attempts to flex the wrist. Exercises. — 1. The patient is seated at the table with the forearm resting on it. The hand is extended over the edge of the table and the palm upward. He attempts to flex the ^wist with and without resistance. Fig. 8L — Forearm supported on table, attempt to flex wrist against resistance. 2. The patient is seated and places the hand as in the second test, ulnar side down. He attempts to flex the wrist with and with- out resistance of the examiner. 222 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Group of Muscles which Extend the Wrist. Muscles. Extensor carpi radialis. Extensor carpi ulnaris. Extensor communis digitorum. Extensor longus pollicis. Neeves. Musculospiral. Posterior interosseous. Posterior interosseous. Posterior interosseous. Muscle Action. — Under normal conditions this group of muscles extends the wrist on the forearm. In case paralysis should occur, the condition of wrist-drop is present here. Test. — The patient places his forearm on the table with the hand over the edge of the table palm down. He then attempts to extend the wrist in this position. Exercises. — 1. The patient places his forearm on the table with his palm down. The exercise consists in extending the wrist against the resistance of the examiner's hand, or without it. Fig. 82. — Forearm suppDrU'd uii table. Attempt to extend wrist against resistance. 2. The patient is seated at the table and places his forearm on the table, ulnar side down. He then attempts to extend the wrist from a position of flexion, with and without resistance. Group of Muscles which Abduct the Wrist. Muscles. Flexor carpi radialis. Extensor carpi radialis. Extensor carpi tilnaris. Extensor longus pollicis. Neeves. Median. Musculospiral. Posterior interosseous. Posterior interosseous. TEST 223 Muscle Action. — This grouj) of muscles abduct the wrist, that is, turn the hand outward, away from the midhne. Fig. 83. — Forearm supported on table ulnar side down, attempt to abduct -ssTist. Fig. 84. — Forearm supported on table ulnar side down, attempt to adduct wTist. Test.— The patient is seated with the forearm on the table, ulnar side down, and tries to abduct the ^Tist by bringing it from the 224 EXAMINATION OF MUSCLES AND MUSCLE TRAINING midline toward the ulnar side. The hand is extended over the edge of the table. Exercise. — ^The patient in this exercise tries to draw the wrist toward the ulnar side with the arm resting on the table. This may be tried with and without resistance. Group of Muscles which Adduct the Wrist. Muscles. Flexor carpi ulnaris. Extensor carpi ulnaris. Nerves. Ulnar. Posterior interosseous. Muscle Action. — Under normal conditions this group of muscles adducts the wrist — that is, draws the wrist toward the radial side. Test. — Exactly as those for abduction, except adduction is done instead of abduction. Exercise. — Same. Group of Muscles which Flex the Fingers. Muscles. Nerves. Flexor digitorum sublimis. Flexor digitorum profundus. Lumbricales. Interossei. Flexor brevis minimi digiti. Median. Anterior interosseous and ulnar. Ulnar and median. Ulnar. Ulnar. Fig. 85. — Illustrating flexion of fingers. Muscle Action, — Under normal conditions this group of muscles flexes the fingers on the hand. In other words, makes a fist. This cannot be done if this group of muscles is paralyzed. EXERCISE 225 Test. — The patient is asked to make a fist or close the hand. Exercise. — In this exercise the patient attempts to flex the fin- gers on the hand by making a fist and drawing the fingers toward the pahn of the hand. Group of Muscles which Extend the Fingers. Muscles. Extensor digit-oruin communis. Extensor indicis proprius. Extensor niinimi digiti. Lumbricales. luterossei. Nerves. Posterior interossei. Posterior interossei. Posterior interossei. Median and ulnar. Ulnar. Muscle Action. — Under normal conditions this group of muscles extends the fingers on the hand — that is, straightens the fingers out. Test. — ^The patient in this test attempts to straighten the fingers from a flexed position. Fig. 86. — Illustrating extension of fingers. Exercise. — The patient in this exercise tries to extend the fingers either from a flexed hand or a closed hand. He tries to straighten the fingers. This may be done with and without resistance on the part of the examiner. Group of Muscles which Abduct the Fingers. Muscles. Nerves. Lumbricales. Median and ulnar. Flexor brevis minimi digiti. Ulnar. Opponens minimi digiti. Ulnar. Dorsal interossei. Ulnar. 15 226 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Muscle Action.- — This group of muscles under normal conditions abducts the fingers. Test. — ^With the fingers adducted — that is, together — ask the patient to abduct them or to draw them away from the midline. Exercise." — ^The exercise consists in making the patient abduct the fingers by bringing them away from the midline. Group of Muscles which Adduct the Fingers. Muscles. Nerves. Palmar interossei (to the middle line of Ulnar, middle finger). Muscle Action.— This group of muscles adducts the fingers. Test.- — Ask the patient to bring together or adduct the fingers. Exercise. — In this exercise the patient makes an attempt to adduct the fingers — that is, bring them together. Group of Muscles which Flex the Thumb. Muscles. Nekves. Opponens poUicis. Median. Flexor brevis pollicis. Median. Adductor pollicis. Ulnar. Abductor pollicis brevis. Median. Flexor longus pollicis. Anterior interosseous. Muscle Action. — ^Under normal conditions this group of muscles flexes the thumb on the hand. Test.^ — With the thumb extended ask the patient to flex the thumb on the hand. Exercise. — The patient attempts in this exercise to flex the thumb and straighten it out again. This is repeated several times and may be tried with and without resistance. Group of Muscles which Extend the Thumb. Muscles. Nerves. Abductor pollicis longus. Median. Extensor pollicis brevis. Posterior interosseous. Extensor pollicis longus. Posterior interosseous. Muscle Action. — This group of muscles, under normal conditions, extends the thumb. EXERCISE 227 Test.^ — Ask the patient to draw the thumb backward toward the dorsal surface of the hand, thereby extending it. Exercise. — In this exercise the patient extends the thumb from a flexed position. This may be tried with and without resistance. Group of Muscles which Abduct the Thumb. Muscles. Nerves. Abductor pollicis brevis. Median. Extensor pollicis brevis. Posterior interosseous. Extensor pollicis longus. Posterior interosseous. Muscle Action. — ^This group of muscles, under normal conditions, abduct the thumb — that is, draw it away from the midline toward the radial side of the hand. Test. — In this test the patient is asked to spread the thumb away from the other fingers by drawing it out from the hand. Exercise. — ^The patient abducts the thumb — that is, draws it away from the fingers in a lateral position, starting by having the thumb adducted at first and then abducting it. Circumduction of the thumb involves a combination of all the muscles that have as their action the flexion, extension, abduction, and adduction of the thumb. Group of Muscles which Adduct the Thumb. Muscles. Nerves. Adductor pollicis obliquus. Ulnar. Adductor pollicis brevis. Ulnar. Adductor pollicis transversus. Ulnar. Flexor pollicis brevis. Median. Opponens pollicis. Median. Interosseous (first dorsal). Ulnar. Muscle Action.^ — This group of muscles adducts the thumb — that is, draws the thumb toward the midline. The thumb is inverted, so to speak. Test.— In this test the patient is asked to draw the thumb inward by bringing the tip of the thumb to the little finger at the meta- carpophalangeal articulation. Exercise.^ — ^The patient is asked to flex the thumb and at the same time bring it toward the ulnar side of the hand. Inverted, as stated above. 228 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Fig. 87. — Illustrating adduction of thumb. Group of Muscles which Flex the Spine Laterally. Muscles. Erector spinas group mentioned before, plus, Rectus abdominis. Obliquus externus. Transversus abdominis. Obliquus intern us. Psoas ma.jor and minor. Quadratus lumborum. Nerves. Intercostal, iljo-inguinal, iliohypogastric. Intercostal, ilio-inguinal, iliohypogastric. Intercostal, ilio-inguinal, iliohypogastric. Intercostal, ilio-inguinal, iliohypogastric. Second and third lumbar. Lumbar and twelfth thoracic. Muscle Action. — This group of muscles bends the body to the side under normal conditions. Gait. — ^When paralysis of this group of muscles occurs, the patient walks with a scoliosis and the body flexed to the opposite side. Tests. — 1. The patient lies on the sound side with the limbs held down firmly and attempts to flex the body laterally to the affected side. 2. The patient lies on his back and attempts to flex the body toward the affected side by trying to bend it laterally. 3. The patient, while standing, attempts to raise the foot of the affected side from the ground without bending the knee or any other part of the body. He tries to draw the pelvis up. Exercises. — 1. The patient is placed in a position on the table, so that the sound side is down and the affected side up. He then tries to flex the body laterally. EXERCISES 229 2. With the patient lying on his back an attempt is made to flex the body laterally toward the affected side. 3. If the patient is able to stand, he makes an attempt to raise the foot of the afi'ected side from the ground without bending the knee. In this way he raises the hip and flexes the side aftected, if he is able. Group of Muscles which Flex the Spine. Muscles. Nerves. Rectus abdominis. Intercostal, ilio-inguinal, iliohypogastric. Pyramidalis. Intercostal, ilio-inguinal, iliohypogastric. Obliquus externus. Intercostal, ilio-inguinal, iliohypogastric. Obhquus internus. Intercostal, ilio-inguinal, iliohypogastric. Transveisalis abdominis. Intercostal, ilio-inguinal, iliohypogastric. Psoas major and minor. Second and third lumbar. Sartorius. Anterior crural. Iliacus. Anterior crural. Psoas. Anterior crural. Pectineus. Anterior crural. Rectus femoris. Anterior crural. Adductor longus. Obturator. Gracilis. Obturator. Obturator externus. Obturator. Muscle Action.- — Under normal conditions this group of muscles flexes the spine — that is, bends the body forward. Gait. — In this condition the patient is unable to walk without his abdomen protruding and the hips flexed. There is a marked lordosis present which appears a little later. Tests. — 1. Have the patient lie down with his arms folded, in a sort of semireclining postm-e, and then make an attempt to sit up if he is able to do so. His knees must be held down while this test is tried. 2. The patient lies flat with his arms folded and from this posi- tion tries to sit up straight. 3. The patient lies on his back and attempts to flex the knees on the chest. Exercises.^ — 1. The patient, in this exercise, lies down in a sort of semireclining position on a back rest which is slanting, or a board, and attempts to assume an upright, sitting posture. 2. In the flat position the patient attempts the exercise as described in the test above by trying to sit up from this position. 3. With the patient lying on his back, an attempt is made to flex the thighs on the chest. 230 EXAMINATION OF MUSCLES AND MUSCLE TRAINING 4. In this exercise the patient lies on his side with arms folded and hips held down and attempts to flex the spine by bringing the body forward. This may be tried first on one side and then on the other. Fig. 88. -Series No. I. Flexion of spine. Patient lying down with knees held and arms folded attempts to sit up. Fig. 89. — Second position. Fig. 90.— Third position. EXERCISES 231 Fig. 91. — Fourth position. Fig. 92. — Fifth position. Flexion completed. Group of Muscles which Extend the Spine. Muscles. (Cunningham). Serratus posterior. Splenius capitis. Splenius cervicis. Sacrospinalis. Semispinalis dorsi. Semispinalis cervicis. Semispinalis capitis. Multifidus. Interspinalis. Intercostal. Diaphragm. Trans versus thoracis. Nerves. Intercostal. External posterior branch of second cervical. External posterior branch of second cervical. External posterior branch, sacral and lumbar. Internal branch of cervical plexus. Branches of cervical nerves. Branches of cervical nerves. Branches of cervical nerves. Internal posterior branch of spinal nerves. Intercostal. Phrenic. Intercostal. 232 EXAMINATION OF MUSCLES AND MUSCLE TRAINING This group of muscles includes the muscles which are sometimes spoken of as the erector spinse group. Muscle Action. — ^These muscles, together with the extensor muscles of the thigh, extend the spine — that is, bend the body backward. Gait.— A patient with paralysis of these muscles can neither stand, sit nor walk. Tests.^ — 1. The patient lies face downward on a table or bed and in this position tries to raise the body from the table by extension. 2. The patient sits with the body bent forward and in this posi- tion attempts to straighten the body by sitting upright. This test may be tried with the assistance of the hands on the hips and thereby assisting or without it. Exercises. — 1. The patient lies face downward as in the test and attempts to raise the body from the table. 2. In this second exercise the patient, after having bent the body forward, tries to sit up straight. Group of Muscles which Abduct the Thigh on the Trunk. Muscles. Tensor fascia femoris. Gluteus medius. Gluteus minimus. Obturator externus (during flexion). Pyriformis. Obturator internus. Gemelli. Sartorius. Gluteus maximus (upper fibers). Nerves. Superior gluteal. Superior gluteal. Superior gluteal. Obturator. Sacral plexus. Sacral plexus. Sacral plexus. Anterior crural. Inferior gluteal. Fig. 93. — Patient lying on unaffected side abducts hip by raising leg with knee straight. Muscle Action. — Under normal conditions this group of muscles abducts the thigh on the trunk. (Some of the muscles concerned EXERCISES 233 have, in addition, anotlier action which will })e found under other headings.) Tests. — 1. The patient lies on the good side and attempts to raise the leg of the affected side laterally from the line of the body. 2. The patient lies on his back and attempts to abduct the leg and thigh by drawing it outward on a line with the body. Exercises. — 1. The patient, while lying on the unaffected side, attempts the abduction of the thigh with and without resistance. 2. The patient lies on his back and attempts to abduct the thigh, the pelvis being held firmly to keep it from moving. Gkoup of Muscles which Adduct the Thigh on the Trunk. Muscles. Nerves. Adductor longus. Adductor brevis. Adductor magnus. Pectineus. Gracilis. Quadratus femoris. Gluteus maximus (lower fibers). Obturator. Obturator. Branch of great sciatic. Anterior crural. Obturator. Branch of sacral plexus. Inferior gluteal. Muscle Action. — Under normal conditions this group of muscles adducts the thigh from the midline. Gait. — In walking, if the patient places one foot in front of the other he will swing the body with each step. Test. — The patient lies on his back with the leg abducted and attempts to bring it to the midline. Exercises.^ — 1. The patient assumes the position on his back and attempts to bring the leg toward the midline after it has been abducted. This may be done with and without resistance. 2. The patient in this exercise lies flat on his back with the knees flexed, the soles of his feet flat on the table, and the knees spread apart. In this position he makes the attempt to bring the knees together with and without resistance. Group of Muscles which Flex the Thigh on the Trunk. Muscles. Sartorius. Iliacus. Psoas. Pectineus. Rectus femoris. Adductor longus. Gracilis. Obturator extcrnus. Nerves. Anterior crural. Anterior crural. Anterior crural. Anterior crural. Anterior crural. Obturator. Obturator. Obturator. 234 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Muscle Action. — Under normal conditions this group of muscles flexes the thigh on the trunk. Gait. — In attempting to walk the patient swings the entire pelvis of the affected side forward in order to bring the leg and thigh forward. This produces a condition of lordosis in a short while. Fig. 94. — Patient seated attempts flexion of thigh. Resistance offered against knee. Fig. 95. — Patient lying on affected side attempts flexion of thigh. Sound leg held up and out of the way. Tests. — 1. With the patient lying on his back an attempt is made by him to bring the knee up to the chest in an endeavor to flex the thigh. EXERCISES 235 2. The patient may be seated with his leg hanging over the bed or table and an attempt is made to flex the thigh. 3. The patient may lie on the affected side and attempt to flex the thigh. In this test the good leg should be held out of the way. Exercises. — 1. With the patient on his back the exercise of draw- ing the knee up to the chest and thereby producing flexion may be tried. 2. With the patient seated the flexion of the thigh by bringing the knee to the chest is a splendid exercise. 3. With the patient lying on his side and the unaffected limb held up and out of the way, flexion, by drawing the knee up to the chest is another exercise. In this some resistance may be offered by the examiner. Group of Muscles which Extend the Thigh on the Trits'k. Muscles. Nerves. Gluteus maximus. Inferior gluteal. Gluteus medius. Superior gluteal. Gluteus minimus. Superior gluteal. Biceps femoris. Great sciatic and external popliteal. Semitendinosus. Branch of great sciatic. Semimembranosus. Branch of great sciatic. Adductor magnus. Branch of great sciatic and obturator. Muscle Action. — Under normal conditions this group of muscles extends the thigh on the trunk. Gait. — In this condition, if the patient attempts to walk, he walks wdth a limp, due to the fact that the foot of the affected side touches the ground very lightly and the good leg is brought forward rapidly. The good leg or unaffected leg is bent at the knee in walking. Tests. — 1. The patient may lie on the table face dow^nward and an attempt should be made to hyperextend the hip with the thigh and leg straight by lifting the leg from the table or bed. This test can also be tried by having the patient lying on the table and allowing his thighs and legs to hang over the edge. In this position he maA' try to extend the thigh with the knee straight. 2. The patient lies on the affected side with his hip flexed and makes an attempt to straighten the thigh and extend it in line with the body. Exercises. — 1. The patient in this exercise lies on his face and attempts to raise the entire leg from the table or bed in hj-per- 236 EXAMINATION OF MUSCLES AND MUSCLE TRAINING extension by bringing the leg up from the table. This may be exercised with and without resistance. 2. Patient assumes the attitude of allowing the lower part of the body to hang over the table — that is, the thigh and leg. An attempt is made to bring the leg up on a line with the body. Fig. 96. — Patient lying on face attempts extension of hips against resistance. 3. The patient can assume the position of lying on the affected side with the thigh flexed. The unaffected side is held out of the way and an attempt is made to extend the leg and bring it in line with the body. 4. The patient lies on his back and the knee is straightened. The entire leg is then raised by the examiner from the table or bed and the patient attempts to bring it down with some resistance being offered. Group of Muscles which Rotate the Thigh Outward. Muscles. Gluteus maximus (lower fibers). Gluteus medius (posterior fibers). Gluteus minimus (posterior fibers). During extension. Quadratis femoris. Pyriformis. Gemelli. Obturator externus. Sartorius. Iliopsoas. Pectineus. Adductor longus. Adductor brevis. Adductor femoris. Biceps femoris. Nerves. Inferior gluteal. Superior gluteal. Superior gluteal. Sacral plexus. Sacral plexus. Sacral plexus. Obturator. Anterior crural. Anterior crural. Anterior crural. Obturator. Obturator. Obturator. Great sciatic and external popliteal. EXERCISES 237 Muscle Action. — lender normal conditions this group of muscles rotates the thigh outward. Tests. — 1. The patient lies flat on his back with legs and thighs straightened out and attempts to rotate the thigh outward. The pelvis must be held. 2. The patient sits on the side of the table or bed with knees flexed and hanging oxev. In this position he crosses the foot of the affected side over the sound side and rotates the thigh out\\-ard by twisting. Exercises. — 1. The patient attempts the crossing over of the affected side and the rotation outward of the thigh by twisting, with and without resistance. Fig. 97. — Patient seated attempts outward rotation of hip. Resistance offered on inner side of leg. 2. With the patient flat on his back he attempts the rotating outward of the thigh, the pelvis being held to keep it from twisting. This mav be done with and without resistance. Group of ]\Iuscles wtiich Rotate the Thigh In^'ard. MuscLE.s. Nerves. Tensor fascia femoris. Gluteus medius (anterior fibers). Gluteus minimus (anterior fibers). Semimembranosus. Semitendinosus. Gracilis? Iliopsoas? Superior gluteal. Superior gluteal. Superior gluteal. Branch of great sciatic. Branch of great sciatic. Obturator. Anterior crural. 238 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Muscle Action. — This group of muscles, under normal conditions, rotates the thigh inward. These muscles also have some other action, the rotation being only a part of their entire action. Fig. 98. -Ptitient seated attempts inward rotation of hip. offered on outer side of leg. Resistance Test. — The patient lies on his back and attempts to rotate the whole leg inward. In order to have an accurate test the foot of the affected side should be rotated outward before this test is attempted. Exercise. — ^The patient attempts the inward rotation of the thigh and leg with and without resistance while lying on his back. Group of Muscles which Flex the Knee. Muscles. " Hamstrings." Sartorius. Gracilis. Semitendinosus. Semimembranosus. Biceps femoris. Gastrocnemius. Plantaris. Popliteus. Nerves. Anterior crural. Obturator. Branch of great sciatic. Branch of great sciatic. Great sciatic and external (popliteal). Internal popliteal. Internal popliteal. Internal popliteal. Muscle Action. — Under normal conditions this group of muscles flexes the knee on the thigh. EXERCISES 239 Gait. — If this group of muscles is paralyzed the patient walks with the leg extended and the foot brought down forcibly. No flexion takes place in walking. Tests. — 1. The patient lies on the table face downward and tries to flex the knee by bringing the heel up. Fig. 99. — Attempt to flex knee. Resistance offered by examiner. 2. The patient lies on the side affected and tries to flex the knee by bringing the leg up. The thigh must be held tightly while this test is made. Fig. 100. — Patient lying on back attempts to flex knee against resistance. Exercises. — 1. The patient assumes the same position as in the test and attempts to flex the knee by bringing the leg up. This exercise may be aided first with assistance and later resistance. 2. The patient, on his affected side, attempts flexion of the knee while the thigh is held firmly on the table. In this, as in the preced- 240 EXAMINATION OF MUSCLES AND MUSCLE TRAINING ing exercise, the examiner can assist or resist the movement attempted. 3. The patient hes on his back and the examiner holds the thigh up in order to allow the patient to attempt flexion of the leg. In this exercise gravity and weight of the leg help in attempting the flexion. Group of Muscles which Extend the Knee. Muscles. Nerves. Quadriceps extensor. Vastus externus. Vastus internus. Crureus. Rectus femoris. Anterior crural. Anterior crural. Anterior crural. Anterior crural. Muscle Action. — Under normal conditions the muscles in this group extend the leg. Fig. 101. -First step in extension of knee. Patient seated on heel of affected side attempts to rise. Assistance by examiner. Gait. — If these muscles are paralyzed the leg is in a condition of flexion and the patient cannot walk unless he supports the thigh anteriorly with his hand or with hyperextension, thereby locking the knee. Tests. — 1. The patient, if possible, tries to sit on his heels in a squatting position and tries to raise himself by putting all the weight on the affected leg. 2. The patient is seated with the leg hanging over the side of the bed or table and tries to extend the leg from a flexed position. EXERCISES 241 3. The patient can also be tested in the lying position, if an attempt is made to extend the leg. Fig. 102. — Second step in extension of knee. Patient has raised himself on affected side. Exercises.. — 1. If the patient is able to sit in the squatting posi- tion and can try to raise himself, this exercise may be tried. Fig. 103. — Attempt to extouJ kn(.'e. Rcbidiance offered by examiner. 2. Seated on the side of the table or bed with the leg flexed, he should attempt to extend the leg with and without resistance and assistance of the examiner's hand. 16 242 EXAMINATION OF MUSCLES AND MUSCLE TRAINING 3. The patient can lie on the side affected or else face down and attempt extension of the leg from a flexed position of the knee. Group of Muscles which Dorsal Flex the Foot on the Leg. Muscles. Nerves. Tibialis anticus. Anterior tibial. Peroneus tertius. Anterior tibial. Extensor proprius hallucis. Anterior tibial. Extensor longus digitorum. Anterior tibial. Muscle Action. — Under normal conditions this group of muscles govern the dorsal flexion of the foot on the leg. Gait. — A person with paralysis of this group of muscles is unable to walk in the usual manner and a peculiarity of gait is noticed. This is seen when the patient attempts to walk and at this time the affected limb will be lifted high off the ground in order to pre- vent the dragging of the toes. Fig. 104. — Illustrating dorsal flexion of foot. Tests. — 1. If the patient is able to stand have him attempt to raise the front part of the affected foot off the ground. If any paralysis is present he will be unable to do this and in addition he cannot stand on the heel of the side which is paralyzed. 2. After this test has been tried or if the patient cannot stand, this second test is useful. In this the patient is seated on the side of the bed or table with the feet hanging over the side. The patient should now attempt to flex the foot on the leg dorsally, first with- out resistance on the part of the examiner and then with some resistance, by placing the examiner's hand on the dorsum of the foot and estimating the strength of the attempted flexion. MUSCLE ACTION 243 3. In this test the patient Hes on the affected side and attempts to flex the foot with and without resistance. The operator must hold the leg on the table tightly, in order to prevent any other muscle movement. Exercises. — 1. If the patient can stand, have him attempt to raise the foot in dorsal flexion by allowing the heel to remain on the ground. 2. The patient should lie on the affected side and with the leg held firmlv he should try to flex the foot on the leg. Fig. 105. — Attempt at dorsal flexion of foot. Resistance by examiner. 3. The patient assumes a position on the table or bed with his face downward. In this position the knee is flexed at right angles and the leg vertically directed. An attempt should be made by the patient to flex the foot on the leg with and without resistance. Group of JNIuscles which Plantar Flex the Foot on the Leg. Muscles. Gastrocnemius. Soleus. Plantaris. Tibialis posticus. Flexor longus hallucis. Flexor longus digitorum. Peroneus longus. Peroneus brevis. Nerves. Internal popliteal. Internal popUteal. Internal popliteal. Posterior tibial. Posterior tibial. Posterior tibial. Musculocutaneous. Musculocutaneous. Muscle Action. — Under normal conditions this group of muscles govern the plantar flexion of the foot on the leg. 244 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Gait. — In walking the patient will attempt to walk on the flat part of the foot, or more likely on the heel with the toes elevated, if any paralysis of this group of muscles is present. Tests. — 1. If the patient is able to stand, have him stand on the foot affected and try to raise himself on the toes of this foot. In case this group of muscles is affected he cannot do this. 2. Let the patient try to walk on the toes of the affected side. 3. If the patient cannot stand, have him lie face downward and, with the foot extended over the edge of the table or bed, let him attempt to plantar flex the foot with and without resistance. 4. The patient lies on the affected side and tries plantar flexion with the leg held firmly on the table by the examiner. This may be done with and without assistance. Fig. 106. — Illustrating plantar flexion of foot. Exercises.— 1. If the patient can stand, have him attempt to raise up on the toes of the affected side and exercise the paralyzed muscles in this way. 2. Let the patient lie down and attempt plantar flexion with and without assistance. 3. The patient may also exercise plantar flexion lying on his side, meaning the affected side. This may also be tried with and without assistance. Group of Muscles which Invert the Foot. Muscles. Nebves. Tibialis anticus. Anterior tibial. Tibialis posticus. Posterior tibial. Muscle Action. — Under normal conditions these muscles invert the foot on the leg. EXERCISE 245 Gait. — In case of paralysis of the muscles which cause inversion of the foot the patient walks on the inner border of the paralyzed foot with the sole of the foot turned outward. This condition is called talipes valgus. Test. — The patient is seated with the leg hanging over the side of the table or bed and then tries to tiun the sole of the foot inward while the examiner holds the leg tightly. Fig. 107. — Inversion of foot. Leg held by examiner. Exercise. — ^The patient in doing this exercise is seated with the foot hanging over the side of the table or bed and attempts to invert the sole of the foot with and without resistance on the part of the examiner. The resistance in this case is offered by placing the hand on the sole of the foot and trying to prevent the inversion of the foot. Sometimes it is best to start this exercise by giving the patient a little help in carrying out this movement. [This may also be done with the patient lying on his back and the leg supported by the examiner. Group of Muscles which Evert the Foot. Muscles. Nerve Innervation. Peroneus tertius. Anterior tibial. Peroneus longus. Musculocutaneous. Peroneus brevis. Musculocutaneous. 246 EXAMINATION OF MUSCLES AND MUSCLE TRAINING Muscle Action. — Under normal conditions this group of muscles everts the foot. Gait. — In case of paralysis of this group of muscles which cause eversion of the foot the patient walks on the outer border of the foot which is paralyzed and the sole is turned inward. This condi- tion is called talipes varus. Test. — ^The patient is seated with the leg hanging over the side of the table or bed and then tries to turn the sole of the foot outward while the examiner holds the leg tightly. Exercise. — In doing this exercise the patient is in the same posi- tion as for the one in which inversion is attempted. He is seated at the side of the table or bed with the leg hanging over and attempts to evert the foot by turning it outward. This may be done with and without assistance and resistance by the examiner. The patient may try this exercise lying down. Group of Muscles which Flex the Toes. Muscles. Nerve Innervation. Flexor longus digitorum. Flexor longus hallucis. Flexor brevis hallucis. Flexor brevis digitorum. Flexor brevis minimi digiti. Lumbricales. Interossei. Accessorius. Posterior tibial. Posterior tibial. Internal plantar. Internal plantar. External plantar. External and internal plantar. External plantar. External plantar. Fig. 108. — "Making a fist with foot." Flexion of toes. Muscle Action. — Under normal conditions this group of muscles flexes the toes in plantar flexion. Tests. — The patient either lies down or is seated, and in this position tries to flex the toes — that is, draw them toward the sole of the foot. The patient may understand more clearly if he is told to make a fist with his toes. THE SPRING-BALANCE MUSCLE TEST 247 Exercises. — To exercise the paralysis of these muscles the patient is placed in the same position as in the test. He should attempt to flex the toes in the plantar direction, first without any resistance, and then with resistance of the hand of the examiner, who pushes against the toes while the patient attempts to flex them. Group of Muscles which Extend the Toes. Muscles. Extensor longus digitorum. Extensor brevis digitorum. Extensor longus hallucis. Xerve Ix.vervatiox. Anterior tibial. Anterior tibial. Anterior tibial. Muscle Action. — Under normal conditions this group of muscles extends the toes by raising them. Test. — The patient either lies down or is seated and then tries to extend the toes by drawing them up toward the dorsum of the foot. Fig. 109. — Attempt to extend toes against resistance. Exercise. — The patient is seated with the legs hanging over the side of the bed or table and in this position he should attempt to extend the toes with and without resistance. Resistance in this exercise is given by the examiner placing his hand on the dorsum of the foot and pressing down while the patient attempts extension. This may also be tried with the patient lying down. THE SPRING-BALANCE MUSCLE TEST. The spring balance muscle test was devised by Lovett and Martin,^ of Boston, and has been used by them very extensively over a period covering almost two years. It is used to estimate the strength of muscle groups and not only indi\idual muscles. This 1 Am. Jour. Orthop. Surg., July, 191G. 248 EXAMINATION OF MUSCLES AND MUSCLE TRAINING test is of value not only in the examination, but also in the diag- nosis and study of the disease. When this work was first started by these two observers the classification of muscles was rather unsatisfactory and at the same time unreliable. Muscles were classified according to the amount of movement as normal, partly paralyzed, or completely paralyzed, depending on their power of contraction. It can readily be seen that as far as the first and last groups are concerned very little difficulty was experienced in group- ing the normal and completely paralyzed groups; but the real diffi- culty was found to be in the class of partially paralyzed muscles. ^jm ^^\ # / ^BBJiS Hi. ^^^^H t , 1 WKmtK0^^^^ tel Fig. 110. — Test for hip flexion. Courtesy of Lovett and Martin (American Journal of Orthopedic Surgery, JuJy, 1916). To this class belonged everything from an almost normal muscle contraction to one almost paralyzed, and little distinction could be made. Since the advent of this test, however, a way has been found to give us not only the qualitative estimation or value of a muscle or group but also the quantitative value, which in itself is of utmost importance, especially as far as the subsequent treat- ment is concerned. In this treatment it has entered the vacancy, so long open, for giving us an idea concerning especially the improve- ment or progressive muscular failure, which we have been unable to estimate in any satisfactory way up to the time of the devising of this test. THE HPRINd-BALANCE MUSCLE TEST 249 In order to give an accurate description we quote from the reprint of Lovett and Martin: "The method is designed to test, under conditions of constant position and leverage, by a series of spring-balance pulls, the power of the muscles which govern the movement of the limbs. The value of the test consists in the possibility of duplicating exactly the conditions of the first test at succeeding ones, so that a definite idea of gain or loss in muscular strength can be registered in pounds. It is applicable for all tests of power in normal muscles, for determining loss or gain in power at stated intervals, and for determining of the degree of initial weakness in paralyzed muscles. Fig. 111. — Apparatu.s used in muscle test. The numbers in the illustration are referred to in the text. Courtesy of Lovett and Martin (American Journal of Orthopedic Surgery, July, 1916). "The accuracy of the test depends upon the training of two per- sons, an operator and an assistant, to coordinate the pull of the muscle and the registration of the pull on the scales, and upon the maintenance with exactness of the positions and leverage relation- ship individually below. Accurate spring-balance scales (No. 5 in Fig. 1) are used of four sizes: 1-4 pounds, graded in ounces; 1-30 pounds, 1-50 pounds, and 1-100 pounds. The readings are taken to the half-pound, except on the ounce scale. "The operator in general controls and maintains the correct position of the subject, stimulates the subject to innervation, braces and guides the limb tested, and calls the moment of give in the muscle tested through watching the action of the muscle itself. The assistant makes the pull along lines accurately determined, begin- 250 EXAMINATION OF MUSCLES AND MUSCLE TRAINING ning and stopping under the direction of the operator. The same command directs the muscular pull of the patient and the scale pull of the assistant. In all cases in which the position of the assistant makes this possible the scale reading is taken by him at the moment when the yielding in the muscle is called by the oper- ator. Except under special circumstances, plantar flexion is the only reading which the operator is required to make. "Twenty-two readings are taken, for each of which the best position of the subject for the accurate reading of the scales and for constant leverage in the limb action has been determined experimentally." In describing the various measurements the numbers used in the illustrations will be referred to. It may be stated here that the following records of movements are taken. It is best to take these in some definite order so that they may be duplicated at a subse- quent examination: Lower Extremitt. Plantar flexion of foot. Dorsal flexion of foot. Inversion of foot. Eversion of foot. Adduction of foot. Abduction of foot. Extension of hip. Flexion of hip. Extension of knee. Flexion of knee. Upper Extremity. Pectoralis muscle. Latissimus dorsi muscle. Anterior deltoid muscle. Posterior deltoid muscle. Extension of forearm. Flexion of forearm. Extension of wrist. Flexion of wrist. Extension of fingers. Flexion of fingers. Adduction of thumb. Quotations of a few of the many tests follows, the mode of procedure being that described by Lovett and Martin in their article : " Plantar Flexion. — The patient lies on his back on a table and braces his foot against a three-to-one lever (No. 1). The hook of the scale is inserted into the ring of the lever upright. The lever must be so adjusted that the ball of the foot in maximum plantar flexion rests squarely upon the lever pad (No. 2), with the upright at an angle of from 60 to 80 degrees to the table. The lever is held in position by C clamps (No. 3). The pull is made by the assistant from the head of the table, with the scale hor zontal and in line with the leg being tested, and is increased in intensity to the point where the muscular resistance is overcome. To prevent slipping on the table the shoulders of the subject are being held by the hip-braces (No. 4). The muscle gives at about 45 degrees of THE SPRING-BALANCE MUSCLE TEST 251 the plantar flexion, with a rather sharp break in the resistance offered to the spring balance. All measurements of degrees are made to the plane of the table unless otherwise specified. The oper- ator guides the position of the foot, stimulates the patient to inner- vation, and calls the moment of the break in the muscle to the assistant for reading or reads the scale himself. The reading of the scale must be simultaneous with this break. " Hip Extension. — The subject lies on the side opposite to that to be tested, with the hips directly one above the other. The abdomen is braced against the hip clamp used in abduction and adduction. At the lower end of the table two C clamps, across which a small board is placed for comfort, are used by the patient for a brace. He pushes against this with the foot of the leg not being tested to secure more steadiness. The trunk is braced forward by the patient by holding to the edge of the table with the hands. The operator maintains the position of the abdomen against the hip-brace with one hand and with the other supports the weight of the leg to be tested, and keeps the leg parallel to the table. The loop is at the knee across the popliteal space. The leg is placed in maximum extension with the knee straight. The direction of pull of the balance is slightly less than 90 degrees to the leg, being deflected toward the trunk, and is exerted horizontally. The angle of the pull must be constant throughout the movement. The operator calls for the reading as the leg crosses the line of the trunk, or if the muscle gives before this, the reading is taken when the muscle yields. " Hip Flexion.— The side position and hip brace, as in hip exten- sion, are used. The small of the back is against the hip brace. The patient maintains the rigidity of the trunk by pushing with the hands against the opposite hip brace. The operator supports the leg parallel to the table, with one hand at the knee and the other at the ankle. The knee is well bent and the thigh is flexed above the right angle. The pull is horizontal and as near as possible at right angles to the femur. The reading is taken when the muscle gives. "Forearm Extension. — The patient lies on the back, with the arm at the side, and the forearm perpendicular to the table, against which the elbow rests. The hand is closed with the thumb point- ing to the shoulder. The loop is at the wrist just proximal to the styloid process of the ulna. The assistant stands at the head of the table and braces with one hand the shoulder of the side to be 252 EXAMINATION OF MUSCLES AND MUSCLE TRAINING tested. The operator braces the elbow on the table with one hand, and with the other at the wrist limits the extension of the forearm. The pull is horizontal. At the direction of the operator the exten- sion of the forearm and the pull of the assistant start together slowly. Extension is permitted to from 5 to 15 degrees from the perpendicular and is overcome by the assistant. The call for reading of the scale is made just as the forearm crosses the vertical line." CHAPTER XVI. THE PREVENTION OF THE DISEASE. During an epidemic physicians are constantly asked how the disease can be prevented and if there is anything that can be done to ward it off. First, let us consider the child itself. If the child has not been definitely exposed to the disease the best thing to do is to keep it in the best possible physical condition and follow out suggestions given in the circulars of information for the public published by the New York City Health Department, which are given later on. There have been numerous suggestions made for protecting the child by the use of antiseptics in the nose and throat. All sorts of solutions have been recommended, such as 5 or 10 per cent, argyrol, 10 per cent, colloidal silver, and the various well-known alkalines and acid antiseptic solutions. The nasal mucous membrane produces watery soluble protective substances that have recently been actually demonstrated. In all probability the use of various antiseptic agents destroys this and so robs the body of a valuable aid in warding off the disease. It is perfectly certain that the prolonged use of anti- septic solutions in the nose produces irritation of the mucous mem- brane and often actual pathological processes. Under normal conditions the nose will look after itself. It has also been shown by experiment that the use of the ordinary antiseptic solutions in the nose will not prevent the experimental disease in monkeys. Except as stated below we are of the opinion that the various measures used in the nose and throat do more harm than good. We therefore advise that in the presence of an epidemic that no antiseptic or irri- tating solutions be used in the nose or throat. If a person has been definitely exposed to the disease, such as a nurse, and it is a question of whether she should be allowed to come in contact with the child, we advise the use of a freshly prepared, 10 per cent, argyrol solution, five drops in each side of the nose while the patient is in a recumbent position, so that it covers the nasopharynx completely, and this amount is instilled three or four times a day for two or three days and then stopped. Whether this is a proper procedure or not will 254 THE PREVENTION OF THE DISEASE have to he determined hy future observations, but we have, at least, had no instance of poUomyeHtis developing in children where a nurse or parent who had been exposed to the disease has used this as a precautionary measure. Where the child itself has been definitely exposed to the disease, we have adopted the same procedure. A modification of the Dakin solution, so that it may be used on the mucous membrane without causing irritation will probably be found to be what is most efficient. Flexner and Clark^ have carried on a series of experimental poliomyelitis in monkeys and found that if the monkeys are given hexamethylenamin before the virus of poliomyelitis is injected into the brain, and if the drug is administered by mouth daily after the injection, a certain proportion of the animals so treated, but not all, will show a prolongation of the incubation period (from six to eight to twenty-four days) and the onset of paralysis may be entirely prevented. Efforts to find a new compound starting with hexa- methylenamin that will exert even a greater action in this regard up to the present time have not been successful. We see no objection and possibly good, in using hexamethylenamin in children who have been definitely exposed to the disease, giving from 1 to 5 grains at a dose according to the age, and giving four or five doses a day. The drug should be given in plenty of water, and we generally continue its administration from one to two weeks after the exposure. If the child develops any signs of irritation of the urinary tract the drug should be immediately discontinued. We do not recommend the indiscriminate use of this drug in individuals who have not been definitely exposed. In the case of individuals who may be carriers, such as nurses and others who have been exposed to the disease, we suggest the use of 10 per cent, argyrol in the nose for two or three days, and such individuals, as far as possible, should be kept away from young children for about eight days. The prevention of a disease like poliomyelitis, where the exact method of transmission has not, as yet, been definitely proved, must include taking the various measures that cover all the possibilities. These have been very well summarized in circulars issued by the New York City Depart- ment of Health, and we do not believe that we can do better than reprint the prophylactic measures as they have published them. 1 Jour. Am. Med. Assn., February 25, 1911, p. 585. ISOLATION OR QUARANTINE 255 The following suggestions for the prevention of the disease have been arrangefl from the report of the Conference of State and Provincial Boards of Health of North America, held at Washington, D. C, May 2 and 3, 1917,^ from the regulations and procedures of the Department of Health of the City of New York- and some of the pamphlets issued by the Department of Health of the Citv of New York during the epidemic of 1916. Some of the paragraphs have been used without any change whatever. The Incubation Period. — For purposes of quarantine the incubation period of the disease may be regarded as within two weeks after exposure. This is important in considering the length of time to quarantine people who have been in contact with the disease. Isolation or Quarantine. — During the epidemic of 1916 a quarantine period was first used of eight weeks. This was shortened to six and, in some instances, to four weeks. This long period of quarantine, if it is not necessary, imposes a needless expense and hardship and leads to the hiding of cases and mitil it has been very definitely established that this long period is important, we would suggest the shorter period of two or three weeks be tried. \Ye are inclined to believe that for the average case this will be shown to be sufficient unless the fever persists or there is discharge from the nose and throat, neither of which is common after that length of time. The reasons for believing that this shorter period will be sufficient are: (1) the numerous instances in ^\hich the diagnosis is not made until late, so that the patient is not isolated for several weeks after the date of onset, and yet no apparent secondary cases appear; (2) the fact that the longest period observed in which a primary case was the source of infection was only ten days; (3) that the epidemio- logical experience for past epidemics does not seem to justify a long period of isolation; (4) the fact that at least one city and one wState have been using a two weeks' period of isolation for all knoAMi cases of poliomyelitis for several years. The patient with the disease should be isolated for the period determined upon, that is, not less than two weeks nor ordinarily over three weeks from the date of onset of the disease as determined by the health authorities, and not from the date of the diagnosis or the reporting of the disease. Children under sixteen years of age (except those who have had 1 Public Health Reports, May IS, 1917. 2 Weekly Bulletin of the Department of Health of the City of New York, June 16, 1917. 256 THE PREVENTION OF THE DISEASE the disease) who remain at home in families in which poliomyelitis has occurred, shall be quarantined in the home until two weeks after the termination of the case by death, removal, or recovery. Adults of the household, if the patient is isolated at home, may continue their vocations, provided this does not bring them into contact with children under sixteen years of age, and provided they are not engaged in the preparation and handling of foods. Adults excluded from their usual occupations and children under sixteen years of age affected by the preceding regulations, provided they remove to, and remain at, a different place of residence and are well at the expiration of two weeks from the date of their last contact with the patient, may resume their usual occupations. Placards. — All premises where a case of poliomyelitis occurs should be placarded (the only exceptions being hotels and boarding houses, provided the patient is at once removed to a hospital and the room or rooms immediately disinfected and provided no quarantined children remain on the premises). In private houses and in two- family houses with separate entrances a placard should be placed on the door entering the room the patient occupies. In apartment and tenement houses a placard should be posted on the door of the apartment occupied by the family of the patient. In two-family houses with a common entrance one placard shall be placed on the door entering the portion occupied by the family of the patient and one upon the room or rooms occupied by the patient. Removal to Hospital. — No patient should be left at home unless the following conditions are complied with to the satisfaction of the Health Department, providing the Health Department has adequate hospital facilities for caring for the cases: (a) There must be a physician in frequent attendance. (6) The patient must have a special attendant, who must obey quarantine regulations and must not do any housework, marketing, or perform any household duties for other members of the family. The attendant may, however, leave the house, provided the neces- sary precautions as to personal disinfection are observed, but all children must be avoided. (c) The patient and the attendant must have a room, or rooms; separate from the rooms of others in the family. (d) All the windows of this room must be screened and all flies in the room killed. (e) The family must have a separate toilet for its exclusive use. (/) Isolation and quarantine regulations must be strictly observed by the patient and other children of the family. HEALTH DEPARTMENT NURSES 257 (g) All discharges from the nose, throat, and bowels of the patients and all articles soiled therewith shall be promptly disin- fected, and attendants shall wash their hands with soap and hot water promptly after handling such discharges or articles. Attendants shall, in the same manner, wash their hands and change their clothing before leaving the room occupied by the patient. All eating utensils and personal and bed-clothing shall be properly disinfected. Requirements for Nurses and Physicians. — The nurse in attendance should wear a cap and gown over her ordinary clothes, which should all be of wash material, and this may be supplemented by the use of a gauze nose and mouth protector such as are used in infectious disease hospitals. This latter procedure was dispensed with in some of the hospitals during the epidemic of 1916, without any apparent spread of the disease by the individuals who were not so protected from becoming carriers, and, no doubt, its use should not be made obligatory. The physician should wear a gown which may be supplemented with a cap and mouth-piece, or not, and both physi- cian and nurse should avoid contact with the patient as far as pos- sible, and also to use every precaution to avoid being soiled by dis- charges and by droplet infection from the patient. On the first visit, if the physician does not have a gown, care should be taken not to allow the clothes to come in contact with the patient or bedding. Before leaving, both the physician and nurse should scrub their hands thoroughly with soap and hot water. The nurse in attendance on a case of poliomyelitis need not be isolated during the whole period, providing she changes her clothes when she goes out and avoids coming in contact with children and frequenting crowded places as far as possible. Terminal Disinfection or Renovation. — After removal, recovery, or death of the patient, disinfection or complete renovation of the room or rooms occupied by the patient and attendant is required, and after recovery of the patient, isolation shall be terminated by a thorough washing of the entire body and hair of the patient. Health Department Nurses. — Nurses should visit every case reported, to instruct the family regarding isolation of the patient and quarantine. Every ^other family in the house^should be warned by her as follows: (a) That there is a case of the disease in the house. 17 258 THE PREVENTION OF THE DISEASE (6) That the other children of the family in which the disease has occurred will be quarantined, and, should they fail to observe quarantine, that fact should be immediately reported to the Depart- ment of Health, in order that steps may be taken to enforce it. (c) Regarding home cleanliness, personal hygiene, the danger of infection by flies, and other general measures which should be taken to prevent infection. (d) To report at once to the department any cases of suspicious illness of children, or any cases of poliomyelitis, especially if there is no physician in attendance. Visits of Parents or Guardians to Hospital Cases.^ — The New York Health Department allows each case to be visited twice during its stay in the hospital by a parent or guardian. If the child is critically ill the parent or guardian is notified and is permitted to visit daily while the child is dangerously ill. When parents or guardians are admitted to the wards they should be gowned the same as the nurse and use the same precautions on leaving. Return of Poliomyelitis Patients. — In cases where poliomyelitis occurs in residents of a town who are temporarily residing outside of it, if the disease develops within two weeks of the time of leaving the town the patient should be permitted to return, provided that it is brought in a private conveyance, that is, a private car, private automobile, carriage or ambulance, and also that the patient goes direct to a hospital which is prepared to care for such cases. Where the case is developed after two weeks, it would seem more logical to make thecommunity in which the disease develops care for it. Return of Children Who have been Exposed to Poliomyelitis. — Children under sixteen years of age temporarily outside of the community in which they usually reside, who have been exposed to infection of poliomyelitis within two weeks, should be allowed to return, provided they come by private conveyance and go directly to their homes. Advance notice of their coming should be sent to the local health authorities and permission obtained from them, if necessary, by telephone. Such children should be visited by the nurse or inspector of the Department of Health and they should be kept in quarantine until two weeks have elapsed from the date of the last exposure. It is not necessary to placard the premises in these cases, but the children should be visited at regular intervals to see whether the quarantine is being broken. NURSE 259 Care of the Patient and Surroundings. — Complete isolation of the patient must be maintained until terminated by order of the Depart- ment of Health. A separate room must be provided for the patient. Xo one musi be allowed in this room except the attending physician, the nurse and the representative of the Department of Health. (a) All rugs, carpets, draperies and unnecessary furniture must be removed before the patient is placed in the room, (h) All windows must be screened or mosquito-netting placed over the bed so as to protect the patient from flies or other flying insects, (c) The sick room must be kept well aired at all times, (c?) The wood- work must be wiped with damp cloths daily. Under no circum- stances must the floor be swept when i1 is dry. It should be sprinkled with sawdust, bits of newspaper, or tea leaves, all thoroughly moistened, and then carefully swept so thai no dust may arise. (e) Toys and books used by the patient must be destroyed by burning after recovery or death. (/) Household pets must not be allowed in the room. Care of Bedding. — All cloths, bed-linen, and personal clothing which have come in contact in any way with the patient must immediately be immersed in a 5 per cent, solution of carbolic acid and allowed to soak for three hours. They may then be removed from the room and must be boiled in water or soapsuds for fifteen minutes. Care of Discharges from the Body. — A sufficient supply of gauze or clean linen or cotton cloth must be provided, and all discharges from the nose and mouth of the patient received on these cloths. After use they must be immediately burned. Bowel discharges and urine must be covered at once with chloride of lime and then be disposed of by emptying into a water-closet. Care of Utensils Used by Patient. — Plates, glasses, cups, knives, forks, spoons, and other utensils used by the patient must be kept for his exclusive use, and under no circumstances removed from the room or mixed with similar utensils used by others. They must be washed in the room in hot soapsuds and then rinsed in boiling water. After use the soapsuds and water must be throAm into the water- closet. Nurse. — A trained nurse or competent attendant must be in sole attendance upon the patient. She must not be allowed to mingle with the rest of the famih', but must be isolated with the patient. The hands of the nurse must be carefully washed in hot soapsuds after each contact with the patient and before eating. 260 THE PREVENTION OF THE DISEASE Termination of Case. — After each case has been ordered terminated by the Department of Health the following procedure must be followed : (a) The entire body of the patient must be washed and the hair washed with hot soapsuds. The patient should then be dressed in clean clothes (which have not been in the sick room during the illness) and removed from the room. (6) The nurse should also take a bath, wash her hair, and put on clean clothes before mingling with the family or other people. General Suggestions. — Children living in a house where there is a case of the disease should be allowed out of doors, but should be kept by themselves. If there is a yard or roof in which they can play they should not be allowed outside of it for at least two weeks after they have been exposed to the disease. Fresh-air outing or vacation camps are permissible, if kept under competent medical supervision and care is taken to exclude any child from an infected family. Where the disease occurs in a school it need not be closed, but the children should be inspected daily by some medical officer. Absolute cleanliness of all homes is essential whether there are cases in them or not; such cleanliness should include: (a) screens in all windows; (6) flies kept out of all rooms; (c) thorough cleanli- ness of all floors, woodwork, bedding, and clothing; (d) avoidance of dust (all sweeping should be done after the floors have been sprinkled with sawdust, bits of newspaper or tea leaves, all thor- oughly moistened ; (e) garbage can kept covered and washed out in hot soapsuds after they have been emptied; (/) no refuse, either of food or other waste, allowed to accumulate. Travel. — As far as possible, traveling during an epidemic should be discouraged, particularly for children under sixteen years of age. The only people who need watching are those who have definitely come in contact with the disease and where they are known it is best to keep them under observation. The use of travel certificates and any attempt to inspect or supervise travelers are certainly useless. Information for the Public Published by the New York City Department of Health. (From a circular issued by the Department of Health of the City of New York.) Infantile paralysis (poliomyelitis) is a catching disease. How it is HOW TO GUARD AGAINST THE DISEASE 2G1 spread is not yet definitely known. In most cases the disease is probably taken directly from a sick person, but it may be spread indirectly through a third person who has been taking care of the patient, or children who have been living in the same household. The early symptoms are usually fever, weakness, fretfulness or irritability, and vomiting. There may or may not be acute pain at this time. Later, there is pain in the neck, back, arms or legs, with great weakness. If paralysis is to occur it usually appears from the second to the fifth day after the sickness begins. Many cases do not go on to paralysis. The germ of the disease is present in the discharges from the nose, throat, and bowels of those ill with infantile paralysis, even in the cases that do not go on to paralysis. It may also be present in the nose and throat of healthy children from the same family. Do not let your children play with children who have just been sick or who have or recently have had colds, summer complaint, etc. For this reason children from a family in w^hich there is a case of infantile paralysis are forbidden to leave their home. If you hear of their doing so, report it at once to the Department of Health. Persons over sixteen years of age, from families in which there are cases of poliomyelitis, may continue at work unless their business has to do with the preparation or handling of food or drink for sale. If you hear of a case in your neighborhood and the house is not placarded, notify the Department of Health. How to Guard against the Disease. In order to prevent the occurrence of this disease, parents should observe the following rules: Keep your house or apartment absolutely clean. Go over all woodwork daily with a damp cloth. Sweep floors only after they have been sprinkled with sawdust, old tea leaves, or bits of newspaper which have been thoroughly dampened. Never allow dry sweeping. Screen your windows against flies, and kill all flies in the house. Do riot allow garbage to accumulate, and keep pail closely covered. Do not allow refuse of any kind to remain in your rooms. Kill all forms of vermin, such as bed-bugs, roaches, and body lice. Pay special attention to bodily cleanliness. Give the children a bath every day and see that all clothing which comes into contact with the skin is clean. 262 THE PREVENTION OF THE DISEASE Keep your children by themselves as much as possible. Do not allow them to visit moving-picture shows or other places in which children may gather. Children should not be kept in the house; they should be outdoors as much as possible, but not in active contact with other children in the neighborhood. Do not take them on a street car unless absolutely necessary, or shopping. Do not allow your children to be kissed. It is perfectly safe to let your children go to the parks and play- grounds if only two or three of them play together; they should not play in large groups, and you should not let them come into contact with children from other parts of the city. Remember that children need fresh air in the summertime, and outdoor life is one of the best ways to avoid disease. If there is a public shower bath in a school in your vicinity send the older children there every day for a shower bath. This is per- fectly safe and will help keep them in good health. Give your children plain, wholesome food, including plenty of milk and vegetables. Keep the milk clean, covered, and cold. Do not allow the milk or any other food to be exposed where flies may alight on it. Wash well all food that is to be eaten raw. In Case of Sickness. Remember that during the hot weather, children are apt to have stomach and bowel troubles. If your child is taken sick with loose movements of the bowels, or with vomiting, do not at once fear that it must be infantile paralysis; it may be simply digestive disturbance. Give the child a tablespoonful of castor oil and plenty of cool water to drink, and send for a doctor at once. If you cannot afford a doctor's services, telephone the Depart- ment of Health, and one will be sent free of charge. If a doctor or nurse from the Department of Health visits your home, give them all the information you can. They are sent to show you how to keep your children well. Do not give your children patent medicines or buy charms of any kind to ward off the disease. The best preventive is cleanliness and strict observance of the rules that have been given. Although there is no specific cure for the disease, much can be State quarantine 2GS done to reduce the amount of crippling caused by the paralysis. It is important to remember that this requires the services of a trained physician and the care of a competent nurse. Unless }'ou can give these to your child, send word at once to the Department of Health, so that the patient may receive proper care in a well-equipped hos- pital. Of the children cared for in hospitals, only one-fourth as many died as of those treated at home. Give your child a fair chance and let the hospital doctors care for it. What the Health Department Will Do. If a case of infantile paralysis occurs in your home, your doctor must at once notify the Department of Health. An inspector will be sent to investigate. He will paste a sign on the door of your apartment, warning all people not to enter. This sign must not be removed except by someone sent by the Department of Health. The inspector and nurse will tell you just what to do to protect yourself and the others in the family. State Quarantine. — A word on this subject may not be amiss, inasmuch as the northern part of the United States in the late sum- mer and fall of 1916 was treated to a governmental vaudeville in the guise of interstate and intercity quarantine. Some years ago, in the South, this shotgun method was frequently used in connec- tion with the miscontrol of yellow fever. With the discovery of the method of transference of the yellow-fever virus this form of barbarism happily passed away. Unfortunately it was revived in 1916, first one State quarantining against the other until all of the group of States were quarantined against each other. An efl'ort was made to inspect travelers and supply them with cards, but there was little or no investigation of the person to whom the card was issued. There was a vast amount of regulation and large forces of Federal, State and municipal officials joined in wasting people's time, money, and patience, with the result that the disease pursued the course which might have been anticipated had nothing whatever been done. State quarantine measures, in fact all others, should deal with the sick individual and those who have been exposed to the disease. Any further supervision will have to be carried out in a manner which will not have any material effect on the spread of the dis- ease, and which will undoubtedly weaken the faith of the people in the wisdom of health authorities. CHAPTER XVIl. BIBLIOGRAPHY. We have not included any special list of references beyond those given in the text, as the class of writers for whom this book was intended will, for the most part, be either out of reach of medical libraries of sufficient size or will lack sufficient time to make the necessary researches. Those particularly interested will find a very full list of references in the Index Catalogue of the Library of the Svrgeon-GeneraVs Office, United States Army. In the first series the list is in vol, x, 1889, p. 438 et seq., and in the second series in vol. xiii, 1908, p. 610 et seq. Other references to the current literature will, of course, be found in the Index Medicus. The reports of greatest interest are those of Wickman, republished in 1913 in New York, as No. 6 of the Nervous and Mental Diseases Monograph Series; the report of the New York epidemic of 1907; The Investigations on Epidemic Infantile Paralysis, by Kling, Wernstedt and Pettersson, printed in English for the Fifteenth International Congress on Hygiene and Demography, Washington, 1912, and to be obtained through the Nordiska Bokhandeln, Stock- holm. The most important contribution is the clinical study by Peabody, Draper and Dochez, which is vol. iv of the monographs for the Rockefeller Institute for Medical Research, published in New York in 1912. The epidemiology is given by Frost in Bulle- tin 90 of the Hygienic Laboratory, United States Public Health Service, 1912; and the treatment in a little work entitled The Treat- ment of Infantile Paralysis, by Robert W. Lovett, of Boston, pub- lished in Philadelphia in 1916. The surgical treatment is given in detail in the book of Oskar Vulpius, 1910, translated in 1912 by Todd. Other articles of interest are those by Seeligmiiller, in Gerhardt's Handbuch der Kinderkrankheiten, vol. v, part i, 1880; by Mary Putnam Jacobi, in Pepper's System of Medicine, vol. v, 1886; by Wharton Sinkler, in Keating's Cyclopedia of the Diseases of Children, vol. iv, 1891. The most recent publications are the monographs on the Epidemic of 1916, by the New York Health Department, and on the Acute Stages, by Draper. CHAPTER XVIII. SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS. Those of us in active practice find it difficult to keep in mind the various anatomical facts which were so familiar in student days, and for that reason we are appending a few of the well-known tables and plates to serve as reminders in the study of cases of poliomyelitis, as the interest in paralytic conditions is greatly enhanced by a knowledge of just what tissues are involved. The older writers differentiated the white part from the gray matter of the nervous system, and later found out that the white part was made up of fibers and the gray of cells. More recently the interrelation of the cells and fibers has been more clearly determined, and the idea of neurons has become all-important in the consideration of disease of the nervous system. The upper, or corticospinal, neuron consists of the tract, including the fibers originating in the cortex, which pass down through the pyramidal tracts and reach the nuclei of the various cranial nerves in the crura, pons, and medulla and thence down the spinal cord, where fibers run to the anterior horn cells. If a lesion occurs in the upper motor neuron the fibers involved degenerate at once below the lesion. This degeneration does not affect the lower motor neuron. This takes away the cortex or other nerve-cell control, and results in a motor paralysis without wasting of the muscles and with a condition of spasticity. The deep reflexes are exaggerated, and if the leg is involved the plantar reflex is extension. The electrical reaction remains normal. The lower, or spinomuscular, neuron starts from the anterior horn cells and passes through the peripheral motor nerves to the muscles. A lesion results in degenera- tion below it with a resulting flaccid motor paralysis, accompanied with muscular atrophy and absence or lessening of the deep reflexes. The plantar reflex, if it can be elicited, is the normal flexion unless the flexor muscles themselves are paralyzed. The following table from Starr shows the localization of the muscular reflex acts in the cord : 266 SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS Localization of Muscular Reflex Acts in the Spinal Cord, Reflex acts. Pupillary reflex through the sympathetic : Dil- atation of the pupil produced by irritation of the neck. Scapular reflex : Irritation of the skin over the scapula produces contraction of the scapular muscles. Biceps and supinator longus : Tapping their tendons produces flexion of the forearm. Triceps reflex : Tapping tendon produces ex- tension of forearm. Scapulohumeral reflex : Tapping the inner lower edge of the scapula causes adduction of the arm. Tapping extensor tendons at the wrist causes ex- tension of the hand. Tapping flexor tendons at the wrist causes flexion of the hand. Palmar reflex : Stroking palm causes closure of fingers ; finger clonus. Abdominal reflex : Stroking side of abdomen causes retraction. Genital reflex : Squeezing the testicle causes contraction of the abdominal muscles. Patella tendon : Striking tendon at knee causes extension of the leg ; "knee-jerk." Achilles tendon reflex : Tapping the Achilles tendon causes flexion of ankle. Foot clonus : Extension of Achilles tendon causes flexion of the ankle. Plantar reflex : Tickling sole of foot causes flexion of the toes. Babinski's reflex : Scratching sole of foot causes extension of great toe and flexion of the others. Mendel's reflex : Tapping the tendons of the toes causes flexion or extension of the toes. Gordon's reflex : Deep pressure on muscles of calf of leg causes extension of the toes. Oppenheim's reflex : Stroking the outer side of the leg near the tibia causes retraction of the toes and contraction of the tibialia anticus. Snasm of anus on irritation. Localization in segment. Fourth cervical to first dorsal. Fifth cervical to first dorsal. Fifth and sixth cervicaL Sixth cervical. Seventh cervical. Sixth to eighth cervical. Seventh to eighth cervical. Eighth cervical to first dorsal. Ninth to twelfth dorsal. First to third lumbar. Second and third lumbar. First to third sacral. First to third sacral. First to third sacral. First to third sacral. First to third sacral. First to third sacral. First to third sacral. Fourth and fifth sacral. It is also of interest to know the location of the segments of the cord in relation to the vertebrae, and this is admirably shown in the figure from Starr on page 268. The figure from Gray, after Jacob, on page 269 shows graphically the part of the nervous system con- trolling the various muscle reflexes and functions, and is most useful in connection with the preceding illustrations. In this connection the level of the cells in the spinal cord is of interest and is well shown in the following table from Starr: SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS 267 Showing the Muscles Represented in Groups of Cells in THE Various Segments of the Spinal Cord. n., ni. IV. V. VL VIL VIIL I. Cervical. CervicaL Cervical. Cervical. CervicaL Cervical. DorsaL Diaphragm. Diaphragm. Sterno- Lev. an g. soap. mastoid. Rhomboid. Rhomboid. Trapezius. Supra- and Supra- and Scalenus. infraspin. Deltoid. Supin. long. Biceps. infraspin. Deltoid. Supin. long. Biceps. Supin. brev. Serratus mag. Biceps. Serratus mag. Pect. (clav. ). Pect. (clav.;. Teres minor. Pronators. Triceps. Brach. ant. Long exten- sors of wrist Pronators. Triceps. Brach. ant. Long exten- sors of wrist and fingers. Pect. (costal). Latis. dorsi Teres major. Long flexors of wrist and fingers. Long flexors of wrist and fingers. Extensor of thumb. Intrinsic muscles of hands. Extensor of thumb. Intrinsic muscles of hands. I. Lumbar. II. Lumbar. IIL Lumbar. IV. Lumbar. V. Lumbar. Quadr lumb. Obliqui. Transversalis. Psoas Psoas. niacus. Iliacus. Sartorius. Quad. ext. cruris. Quad. ext. cruris. Obturator. Adductores. Obturator. Adductores. Glutei. Glutei. Biceps femoris. Semi-tend. Popliteus. L Sacral. n. Sacral. III. Sacral. IV. and V. Sacral. Biceps femor Semi-memb. Ext. long. dig. Gastroc. Tibialis post Gastroc. Tibialis post. Tibialis anticus. Peronei. Intrinsic muscles of foot Peronei. Intrinsic muscles of foot Sphincter ani et vesicae. Perineal muscles. 268 SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS The relation of the various tracts of the cord are of importance, and to aid in the differential diagnosis and the study of exceptional -^ N. io rectus lateralif to rectuB antic* minor Anaetomoais vAth hypogloeaal AnastomoRiB with pneumogaairic iV. to rectus antic, major, N.to mastoid region . Great auricular n, Transverse carvical n . VirJiS ^' to Trapezius, Ang» Scap. and R?tomboid. Svpra clavicular n, Su2tra-acromial n . -Phrcnia n. -^A. to Icvattyr ang. scap. - N. to rhomboid -—Subscapular n. Subclavicular n. . N. to peetoralis major. Post, thoraic Circumjlcx «. __Mu8culo-mitaneou» n. _Median n, .Radial n, _ Ulnar n , _ Internal cutaneous n. ■VU ' ^VIU [^X7/ ^ 'l)^-^ |^P>^ >M Ilio-hgpogaetrie n. l^^fV ^\.._.2lio-inQuinal w. ^^^"V ^\. internal cutaneous n / U-^ IT^ X Genito-crv/ral «. y^^ST ij V 5w/ ^ Anterior crural n. LS.ll/ /— Obturatorn. Superior gluteal n. A. toUvatorani i^\ JV, to obturator int. — Ni to o2)hincter ani. — Coccygeal n. .iV. to gemellus infer, -N* to guadratus _ Small sciatic n. .. Sciatic n. Fig. 112. — The relations of the segments of the spinal cord and their nerve roots to the bodies and spines of the vertebrae. (Starr.) cases we have included on pages 270 and 271 the figure and the explanatory tables from Jelliffe and White: SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS 269 LOCATION OF THE SEGMENTS FOR Sensibility. Motility. Thoracic and abdominal Occipital region Front of neck Back of neck Shoulder (Musculo- spiral n. Median n. Ulnar n. Inferior abdominal reflex Gluteal region Inguinal region Hips C -interior Thigh I Median 1 External \_ Posterior j^i Internal i External Foot Scrotum, penis, etc. — Bladder, rectum *.. Amis — — — Sphincter iridis Ciliarit ^^ Rectus int., levator palpehr, 8up, Rectus inf. and sup. "•■^'Obl. infer. Obi. super. Masseter, temporal, pterygoids Rectus extern. Occipitofront., orbicularis oculi iupperfacial\ Muscles of expression {lower facial) Palatal and pharyngeal muscles Muscles of the larynx Muscles of the tongue Sternomastoid Deep muscles of the neck Sca'eni Trapezius, terratus nticu^ Diaphragm Delt., biceps, pectoral, maj. {clavie, portion) 1 ^ Brachial, antic, supinator longus > 2 7Viceps,latis.dorsi,pect. maj. (costal *' ))3 Extensores carpi et digitorum ■» Flexores carpi et digitorum J ^o^'<'"^ Interossei, lumbricales "» Thenar, hypothenar ) Intereoitala Muscles of the back Abdominal musclet — Iliopsoas "V Sartorius I Adductors C "*''"* Abductors ) Quadriceps \ Flexors V Leg Extensors j ,..— Peronei Flexors, extensors of the foot and toe* Glutei (f) Perineal f Vesical > Musculature Rectal ) Fig. 113. — Explanation of abbreviations: tr. olf., olfactory tract; c. g. I., lateral geniculate body; p, r, cr, A, indicate approximately the location of the reflex centers for the pupillary (p), the respiratory (r), cremasteric {cr), patellar (pat), and tendo- Achilles (A) reflexes. The vesical center lies in the third and fourth sacral segments; the anal center in the fourth and fifth (represented by circles) ; the centers for erection, ejaculation, labor pains (?) are probably also situated in this region. In reality, the divisions between the various segments are, of course, not so sharp as they are shown in the diagram, so that a given muscle or cutaneous region derives some of its con- trolling nerve roots from the segments lying immediately above and below the principal segment. The sensory segment for any given region is regularly somewhat higher than the corresponding motor segment. (Gray.) 270 SOME ANATOMICAL AND PHYSIOLOGICAL REMINDERS Radices dor salts /+/If Hadices cervicale. Posterior Root Zom Radices dor sales V+XII I Radices lumbares J sacrales ^^Oval Field Descending dorsal root fibers -Marginal Zone ractus corticospinalia cerebello spinalis posterior Limiting Layer- Tractus cortico spinalis cruciatus] Tractus cerebello' spinalis anterior Fibrae associativae breves Fibrae associativae longae Fasciculus longitudinalis dorsalia Fig. 114. — Cross-section of spinal cord, showing localization of chief structures with lesions. (Jelliife and White.) Location of Lesion. 1. In the posterior root zone. 2. In posterior column of one side. 3. In Goll's columns of both sides. 4. In central gray, especially of anterior commissure. 5. Posterior portion of the lateral columns with integrity of limiting layer. 6. Pyramidal tracts. 7. Anterior horns. 8. Spinocerebellar paths. 9. Lateral recess. Chief Symptoms. Irritation causes hyperesthesise. Destruc- tion causes loss of superficial sensibility in the root distribution spreading over at least three roots. Ataxia and event- ually astereognosis in the extremity involved. Anesthesia to deep sensibility and to touch. Ataxia of metameres below the lesion. Anesthesia to deep sensibility and hypes- thesia of the lower extremities only, even in high lesions. Dissociated sensibility (thermanesthesia and analgesia in the affected metameres as indicated in the skin distribution). Crossed hemihypesthesia plus the symp- toms of 6. Spastic paralysis of the caudal metameres below the lesion without reaction of degeneration, often crossed movements, no atrophy and with increased reflexes. Flaccid paralysis of the muscles of a num- ber of root zones, atonia and atrophy of muscles of involved metameres; R.D., loss of reflexes. Bilateral involvement causes cerebellar ataxia. Sympathetic disturbances metamerically distributed. The study of the nervous system in poliomyehtis has largely been limited to the motor neurons, owing to the fact that the symptoms are so forcibly impressed upon the observer. The sensory side ,is worthy of study, even if not so important or the changes so per- manent. SOME ANATOMICAL AND PIIYSIOLOCICAL REMINDERS 271 ►J o 02 ■* to CD t^ o a ri S <« g » c3 G o o O o r^ 5i d .in o ^ rf r^ o '^ t\ bH^ o r-H oq CO "* o 12; o |i O X 03 ■=« ft O - M CD O ^ T3 Q o o .2^ oT o o o3 TIJ ;S ?^ w '1 ft 3x c ;=! QJ •>: ><+H g a^ ^ O faC g ^ > f^ 1>^ 6 H ^ Sft Q ft 3 1^ 13 tS o ►> O iJ ;-< O bX) > ^^ O 1— 1 o ,-1 o3 tc rd < o « 'T^ ombi ram: 6 an s 1914 Michigan 49 57.0 1914 Minnesota 19 68.0 1914 Mississippi 113 20.0 1914 New Jersey 32 ? 1914 New York 224 31.0 1914 Ohio 63 ? 1914 South Carolina 21 ? 1914 August-October Vermont 301 17.0 1914 August-October Washington 21 42.0 1914 August-November Wisconsin 31 35.0 1915 California 62 30.0 1915 August-November Connecticut 35 11.0 1915 Indiana 36 47.0 1915 Kansas 48 31.0 1915 July-August Maryland 66 ? 1915 September-October Michigan 71 42.0 1915 September-No vem ber Minnesota 127 20.0 1915 Mississippi 85 ? 1915 . . • New Jersey 36 ? 1915 New York 257 16.0 1915 July-November Ohio 466 ? 1915 August-November Vermont 42 40.0 1915 Virginia 241 ? 1915 ... Washington 10 30.0 1915 , . Wisconsin 14 78.0 Poliomyelitis in 1916 in the United States. Public Health Reports of the United States Public Health Service, June 1, 1917. Cases reported. Alabama 186 Arizona 6 California 132 Colorado 16 Connecticut .... 951 District of Columbia . . 39 Indiana 207 Iowa 259 Kansas 103 Kentucky 146 Louisiana 77 Maine 149 Maryland 352 Massachusetts .... 1,926 Michigan 616 Minnesota 909 Mississippi 269 Montana 94 New Jersey 4,055 New York 13,223 Indicated Indicated Deaths case rate fatality Estimated regis- per 1000 rate per population tered. inhabitants. 100 cases. July 1, 19](i 51 0.080 27.42 2,332,608 0.023 255,544 26 0.045 19.70 2,938,654 0.017 962,060 235 0.764 24.71 1,244,479 6 0.107 15.38 363,980 50 0.073 24.15 2,816,817 51 0.117 19.69 2,220,321 26 0.056 25.24 1,829,545 48 0.061 32 . 88 2,379,639 18 0.042 23.38 1,829,130 0.193 772,489 111 0.258 31.53 1,362,807 424 0.518 22.01 3,719,156 138 0.202 22.40 3,054,854 105 0.399 11.55 2,279,603 31 0.138 11.52 1,951,674 26 0.205 27.66 459,494 1180 1.376 29.10 2,948,017 3331 1.287 25.19 10,273,375 282 EPIDEMICS Indicated Indie ated Deaths case rate fatality Estimated Cases regis- per 1000 rate per population reported. tered. inhabitants. 100 cases. July 1, 1916 Ohio 546 0.106 5,150,356 Oregon . 38 4 0.045 10.53 835,471 Pennsylvania 2,181 0.256 8,522,017 South Carolina 123 36 0.076 29.27 1,625,475 Texas 86 35 0.019 40.70 4,429,566 Vermont 64 12 0.176 18.75 363,699 Virginia . 330 59 0.151 17.88 2,192,019 Washington 30 7 0.020 23.33 1,534,221 West Virginia 82 0.059 1,386,038 Wisconsin . 475 79 0.190 16.63 2,500,000 Wyoming 7 3 0.039 42.86 179,559 No satisfactory figures covering the past few years for European countries are available. An account of the prevalence of the disease throughout the world in recent times is given by Bruce Low.^ REFERENCES. 1. Colmer: Am. Jour. Med. Sc, 1843, v, 248. 2. McCormac: Lancet, 1842-3, ii, 301. 3. Bergenholz: Medin, Arch. d. med. v. Enfants, 1898, 257. 4. Sinkler: Boston Med. and Surg. Jour., November 23, 1898, p. 16 (quoted by Frauenthal and Manning in their book Infantile Paralysis) . 5. Bergenholz: Reference in Medin Hygeia, 1890, lii, 657. 6. BuchelU: 11 PoUclinico, 1897, iv, 249. 7. 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Report on the New York Epidemic of 1907 by the Collective Investigation Committee, Nervous and Mental Diseases, Monograph Series No. 6, 1910. 60. Harbitz: Jour. Am. Med. Assn., 1912, lix, 782. 61. Lovett: Massachusetts State Board of Health, 1908, p. 756. 62. Griffin: Jour. Michigan State Med. Soc, 1908, \ai, 49. 63. McCombs: Arch. Pediat., 1908, xxv, 37. 64. Free: Jour. Nerv. and Ment. Dis., 1908, xxv, 259. 65. Report of the New York Epidemic of 1916. 66. Dixon and Karsner: Am. Jour. Dis. of Child., 1911, ii, 221. 67. Report of the New York Epidemic of 1916. 68. Bierring: Int. Med. Jour., 1912, xix, 35. 69. Hoffman: Quoted by Netter, Bull, de I'Acad. de med., No. 10, Ixiii, 458. 70. Treves: Brain, 1909, xxxii, 285. 71. Harbitz: Jour. Am. Med. Assn., 1912, lix, 782. 72. Manwaring: Jour. Michigan State Med. Soc, 1909, ^•iii, 161. 73. Schwarz: St. Petersburg Med. Wchnschr., 1909, xxxiv, 21. 74. McCreery: Iowa Med. Jour., 1910, .xvi, 519. 75. Hamilton: Jour. Minnesota Med. Assn. and Northwestern Lancet, 1910, XXX, 2. 284 EPIDEMIC^ 76. Stephen: Intercolonial Med. Jour. Australia, 1902, xiii, 573. 77. Zappert: Wien. med. Wchnschr., 1909, lix, 2683. 78. Manning: "Wisconsin Med. Jour., 1909, vii, 611, and Woman's Med. Jour., 1910, XX, 118. Correspondence -ftTth State Board of Health of Wisconsin. 79. Lovett and Emerson: Monthly Bull. Massachusetts State Board of Health, 1909, n. s. iv, 139, 146. 80. Wiley and Darden: Jour. Am. Med. Assn., 1909, Hi, 617. 81. Hamilton and Hill: Jour. Minnesota Med. Assn., 1910, xxx, 2, 5. 82. Armstrong: 1910, xii, 496. Anderson: Anderson Pediatrics, 1910, xxii, 543, Western Med. Rev., 1910, XV, 391. McClonahan: Jour. Am. Med. Assn., 1910, Iv, 1160. 83. Miiller: Mimchen. med. Wchnschr., 1909, Ivi, 2460. Romer: Die epidem. Kinderlah., Berlin, 1911. 84. Reckzeh: Med. Klinik, 1909, No. 45, v, 1704. Krause: Deutsch. med. Wchnschr., 1909, xxxv, 1825. Potpeschnigg: Arch. f. Kinderkr., 1910, liv, 343. 85. Netter: Bull, et mem. de la Soc. med. de hop. de Paris, 1909, xxviii, 554, 746. 86. Reckzeh: Med. lOin., No. 45, v, 1704. Krause: Deutsch. med. Wchnschr., 1909, xxxv, 1825. Potpeschnigg: Arch. f. Kinderkr., 1910, liv, 343. 87. Bull, de I'Acad. de med., 1910, Ixiii, 458. 88. Lovett and others: Bull. Massachusetts State Board of Health, 1910, n. s., V, 241. 89. Lebredo and Recio: Sanidad y Beneficia, 1910, iii, 170. 90. Harbitz: Jour. Am. Med. Assn., 1912, lix, 782. 91. Harbitz: Jour. Am. Med. Assn., 1912, lix, 782. 92. Report of the New York Epidemic of 1916. 93. Ferreira: Bull, de la Soc. d. ped. de Paris, 1911, xiii, 370. 94. Correspondence Section of State Board of Health. 95. Correspondence Section of State Board of Health. 96. Correspondence Section of State Board of Health. 97. Correspondence Section of State Board of Health. 98. Correspondence Section of State Board of Health. 99. Landolt: Cor.-Bl. f. schweiz. Aerzte, 1911, xli, 1144. 100. Report of Committee of Medical Association of District of Columbia, Wash- ington Med. Ann., 1911-12, x, 81. 101. Grosgeorge: La Polio. Epid. en Anjou. Theses: Fac. de med., Paris, 1911. 102. Gundrum: California State Jour, of Med., 1913, xi, 193. 103. Report of the New York Epidemic of 1916. 104. Harbitz: Jour. Am. Med. Assn., September, 1912. 105. Netter: Bull, de I'Acad. de med., 1910, Ixiii, 458. 106. Dixon and Karsner: Am. Jour. Dis. Child., 1911, ii, 221. From cor- respondence with Pennsylvania State Board of Health. 107. Hyde: Northwest. Med., 1910, n. s. ii, 327. 108. Frost: Hyg. Lab. Bull., No. 90 (United States Public Health Service). 109. Lovett: Infantile Paralysis in United States in 1910. 110. Correspondence Section of State Board of Health. 111. Lovett: 112. Lovett: 113. Lovett: 114. Frost: 115. Lovett: 116. Lovett: 117. Batte, John: Cincinnati. 118. Lovett: 119. Lovett: Correspondence Section of Massachusetts State Board of Health. 120. Green, B. F., of Hillside: 121. Lovett: EPIDEMICS 285 122. Lovett: 128. Correspondence Section of State Board of Health. 124. Lovett: 125. Lovett: 126. Frost: 127. Lovett: 128. Correspondence Section of State Board of Health. 129. Report of the New York Epidemic of 1910. 1.30. Bull. South Carolina State Board of Health. 131. Frost: 132. Lovett: 133. Lovett: 134. Correspondence Section of State Board of Health. 135. Correspondence Section of State Board of Health. 136. Correspondence Section of State Board of Health. 137. Lovett. 138. Russen, Colin, Montreal. 139. Lovett: 140. Lovett: 141. Mejrer: 142. Gundrum: California State Joui-nal Med., 1913, xi, 193. 143. State Medical Institute of Sweden Report; Investigation on Epidemic Infantile Paralysis, 1912. 144. Frost: Hyg. Lab. Bull. 90, U. S. Public Health Service. 145. Frost: Hyg. Lab. Bull. No. 90 (United States Public Health Ser^^ce). 146. Acuna and Schweizer: Rev. Soc. nied. arg., 1911, six, 449. 147. DeBiehler: Ai-ch. de med. des inf., 1914, x\'ii, 1. 148. Harbitz: Fifteenth Internat. Con. of Hyg. and Demog., 1912, pt. 2, i, 577. 149. Cross: British Med. Jour., 1912, i, 721. Local Government Board, Great Britain, 1911-12, xli, 29. Tomkris: British Med. Jovir., 1912, i, 182. England: British Med. Jour., 1911, ii, 1691. Roth: Lancet, 1913, ii, 1378. Gregor and Hopper: British Med. Jour., 1911, ii, 1154. Moss-Blundell: British Med. Jour., 1911, ii, 1157. Saltan: British Med. Jour., 1911, ii, 1151. 150. Hiller: British Med. Jour., 1911, ii, 1690. Moir: British Med. Jour., 1911, ii, 1693. Jubb: Lancet, 1915, i, 67. INDEX OF AUTHOES. See Also List of References ix the Chapter on Epidemics Abramson, 42 Amoss, 30, 41, 42, 168, 172 Anderson, 29, 87 Auerbach, 122 B Baas, 20 Badham, 19, 114, 165 Banzhaf, 173 Barlow, 73, 204 Barthez, 25, 73 Bartsch, 19 Batten, 63 Bergenholz, 28 Bernard, Claude, 132 Bernhardt, 28 Bouchut, 73 Bou^■ie^, 26 Bramwell, 64 Brown, 48 Bruck, 19 Brush, 140 Bull, 48 Biilow-Hansen, 28, 47 Caverly. 28 Cepelka, 131 Charcot, 27, 28, 73 Chassaignac, 26 Chesnev, 168 Clark, 176, 254 Ckrke, 27 Colmer, 25 Cook, 189 Cordier, 28 Cornil, 26 Creel, 59 Crouzon, 163 Dam-vschino, 27 Dana, 137 Demnie. 27 Dixon, 47 Dochez, 27, 75, 83, 84, 103, 106, 108, 116, 131, 132. 159, 175. 264 Draper. 27, 30, 68. 75. S3. 84. 103. 106, 108. 116. 124, 131, 132. 159, 160, 173, 175. 264 DuBois. 141 Duchenne. 25, 28, 64, 73, 81, 162 Duncan, 175 ECHEVEREL\, 27 Emerson, 53, 67 Erb, 28, 73, 183 Erlacher, 202 Eshner, 123 Feltox, 140 Fischer, 68 Flexner. 29. 30. 41. 42. 44, 48, 50, 51, 69, 167, 172, 173, 254 Fliess, 26 Forster, 123 Foiderton, 47 Fox, 47 Freese, 48 Frost, 29, 87, 264 Gallie, 200 Geirsvold, 47 Gray, 267 Gule, 73 288 INDEX OF AUTHORS H Hall, Marshall, 18, 73 Hammers, 140 Hammond, 28 Harbitz, 27, 28, 32, 38, 47, 75, Havens, 51 Heine, 20, 21, 25, 26, 73 Herz, 200 Herzog, 42, 47 Higier, 130 Hoffman, 130 Hogue, 131 Holt, 74 Howland, 74 Huntemliller, 50 Hutin, 19, 26 Jacobi, 27, 264 Jelliffe, 268 Joffroy, 27 Jorg, 19 Joseph, 29, 50, 167 K Kennedy, 25 Klein, 26 Kling, 42, 56, 57, 264 Kocher, 276 Kolmer, 48 Krause, 50, 74, 133 Kussmaul, 28 Laborde, 26, 27 La Fetra, 87 Lanceraux, 27 Landolt, 92, 165 Landry, 89 Landsteiner, 29, 41, 50 Lange, 199, 200 Leegaard, 28, 122 Leiden, 27 Leiner, 29, 50 Lents, 50 Levaditi, 29, 41, 50, 56, 57, 167 Lewis, 29, 41, 42, 50, 51, 69, 167, 176 Lindner, 157 Longet, 26 Lovett, 99, 100, 118, 162, 164, 181, 183, 196, 201, 202, 204, 247, 249, 250, 264 Low, 281 Lucas, 118 M Maccormac, 47 MacPhail, 28 Mally, 157 Marie, Pierre, 28, 84, 87, 163 Marks, 51 Martin, 162, 204,- 247, 249, 250 Mathers, 47, 48 Maxcy, 140 Medin, 26, 28, 32, 38, 52, 80, 81, 85, 88, 113, 114, 122, 126 Meinicke, 50 Meltzer, 166, 175, 176 Merriman, 18 Meyer, 28 Miller, 140 Mitchell, 17 Mobius, 87 Morton, 63 MuUer, 65, 75, 103, 108, 122, 126 N Neal, 141 Netter, 29, 88, 167, 168, 172 Neurath, 87 Neurot, 123 Neustaedter, 43, 50, 62, 173 Nicoladani, 198 NicoU, 70 Noguchi, 29, 44, 46, 48, 149 Nonno, 81 Nuzum, 42, 47 Oppenheim, 87 Parrot, 27 Pasteur, 47 Pastia, 41 Peabody, 27, 75, 83, 84, 103, 106, 108, 116, 131, 132, 159, 175, 264 Pettersson, 42, 264 Pierret, 27 Popper, 29 Prevost, 27 Raymond, 27, 163 Rilliet, 25, 73 Rissler, 27, 32, 38, 81 Roger, 27 INDEX OF AUTHORS 289 Rorner, 29, 41, 50, 167 Rosonau, 51, 59 Rosenow, E. C, 47, 48 Rucker, 47 Sachs, 88 Salaniei', 168 Scheel, 27, 32, 38, 47, 75, 86 Schultze, 27, 28 Schwartz, 123, 168 Seeligmiiller, 26, 27, 117, 163, 264 Seguin, 28, 73 Sever, 119 Shaw, 19 Simpson, 59 Sinkler, 55, 64, 264 Sophian, 174 Spieler, 116, 130 Spitzy, 202 Starr, 265, 267, 276 Steindler, 202 Stoeffel, 202 Strauss, 27, 29, 32, 39, 137 Strlimpell, 27, 28, 35, 75, 84, 124 Tedeschi, 108 Thro, 43, 62 Towne, 47, 48 U Underwood, 17, 18, 26, 73 VizioLi, 84 Vogt, 28 von Heine, Bernard, 21 von Heine, Georg, 20 von Heine, Jacob. {See Heine.) von Heine, Karl, 21 von Recklinghausen, 26 von Reinicker, 26 von Wiesner, 29, 41, 50 Vulpian, 27, 73 Vulpius, 264 W Wernstedt, 42, 264 West, 25, 73, 93 Wheeler, 47, 48 White, 268 Whitman, 200, 201 Wickman, 27, 28, 32, 38, 52, 55, 56, 57, 60, 74, 76, 78, 83, 87, 88, 108, 113, 114, 116, 122, 126, 129, 130, 157, 264 Wiener, 41 Wright, 204 Zappert, 74, 84, 116, 157 19 GENERAL INDEX. A Abdominal paralysis, treatment of, 198 Abducens, 108 Abortive form, 74, 76 Accuracy of diagnosis, 146 Acidosis, 80, 147 Acute fatty atrophic paralysis, 73 infantile paralysis, 73 spinal paralysis, 73 Adenoids, 67 Adrenalin treatment, 175 Adults, 28 Age, 63 and mortality, 158 Albumin test, 139 Alert cerebration, 78 Amaurotic family idiocy, 150 American death-rates, 158 Anatomical reminders, 265 Anihials, transmission to, 49 Anorexia, 78 Anterior poliomyeUtis, 73 Antipohomyehtis horse serum, 173 Arthrodesis, 201 Ascending type, 89 Astragalectomy, 201 Ataxia, transient, 83 Ataxic cases, 80 form, 74 Athetosis, 85 Atrophic paralysis, 73 Attacks, second, 123 Auditory nerve, 113 Autotherapy, 175 B Babinski's reflex, 267 sign, 88 Back muscle paralysis, 103 Bacteriology, 47 Bed-bug, 58 Bed-sores, 134 Bedding, care of, 259 Bell's paralysis, 112, 150 BibUography, 264 Blood, 131 Bones, changes in, 38 Brain, pathology of, 35 Breast-fed infants, 61 Bronchitis, 132 Bronchopneumonia, 147 Brudzinski's signs, 79, 145 Bulbar form, 74 paralysis, 115 Caee of bedding, 259 of discharges, 259 of patient, 259 of surroundings, 259 of utensils, 259 Carriers, passive, 51 treatment of, 254 Cases, paralysis, 98 termination of, 260 Cell counts, cerebrospinal fluid, 138 Cerebral thrombosis, 149 type, 27, 83 Cerebration, alert, 78 Cerebrospinal fever, 149 fluid, 138 colloidal gold test, reaction of, 140 encephahtic meningitis, 143 Fehling's reaction in, 143 Froin's reaction in, 143 macroscopic appearance of, 140 in meningismus, 143 in poliomyehtis, 141 meningitis, 149 Cervicobracliial plexus, 274 Chemical stucUes of spinal fluids, 143 tests, 139 Chevne-Stokes breathing, 113 Child, tj'pe of, 68 Chorea, 150 Choroid plexus and the virus, 42 Cihospinal gangha, 108 Classification, 74 Holt-Howland, 74 Ivrause, 74 Miiller, 75 292 GENERAL INDEX Classification, New York Health De- partment, 75 Peabody, Draper, and Dochez, 75 Wickman, 74 Zappert, 74 Colloidal gold reaction, 140 Conception of the disease, 30 Condition after recovery, 161 Congenital spastic paralysis, 150 Constipation, 78, 133 Contact, 59 Convalescent stage, treatment of, 177 Convulsions, 126 epileptic, 83 Cord, atrophy of, 36 Cranial nerves, 108 affection of, frequency of, 114 Croup, 147 Cultivation of a micrococci, 47 of Noguchi and Flexner organism, 44 Cutaneous nerves, 273 Cyclic vomiting, 147 Day of disease and death, 160 Death, 159 and day of disease, 160 rates, American, 158 foreign, 158 infant, 72 Decayed teeth, 68 Deformities, 116 equinus, treatment of, 195 hand, 118 hyperextension of knee, treatment of, 197 knee, treatment of, 196 knock-knees, treatment of, 197 prevention of, 179 Degeneration, reaction of, 156 Delayed paralysis, 122 Dehrium, 78, 126 Dental paralysis, 73 Diagnosis, 144 accuracy of, 146 acidosis, 147 amaurotic family idiocy, 150 Bell's paralysis, 112, 150 bronchopneumonia, 147 cerebral thrombosis, 149 cerebrospinal fever, 149 meningitis, 149 chorea, 150 congenital spastic paralysis, 150 croup, 147 cychc vomiting, 147 diarrhea, 147 differential, 146 Diagnosis, diphtheria, 147 diphtheritic paralysis, 151 electricity in, 152 facial paralysis, 150 hysteria, 148 laryngitis, 147 meningismus, 149 mental deficiency, 150 nephritis, 147 paralysis, 93 peripheral neuritis, 151 Pott's disease, 150 pseudoparalysis, 147 rabies, 125 rickets, 148 scurvy, 147 spasmophilia, 148 Tay-Sachs' disease, 150 tetany, 148 transverse myelitis, 150 tuberculous meningitis, 148 uremia, 147 vomiting, cychc, 147 Diaphragm, paralysis of, 104 Diarrhea, 133, 147 Differential count, 138 diagnosis, 146 Diphtheria, 147 Diphtheritic paralysis, 151 Diphtheroid bacilh, 48 Diplococci, 48 Discharges, care of, 259 Dislocations, 119 Distribution, geographical, 53 of paralysis, 98 of sensory nerves in the skin, 272 Disturbances, sensory, 129 of speech, 126 of taste, 126 Dromedary group, 30 Drugs, treatment with, 166 Dry skin, 130 Duration of serum, 171 Dust, 60, 62 Dyspnea, treatment of, 165 Ear, 113 Education, 72 Eighth nerve, 113 Elbow, 118 Electricity, 28 in diagnosis, 152 treatment by, 183 Eleventh nerve, 113 Emotional states during convalescence, 130 Encephahtic form, 74 Epidemics, 277 GENERAL INDEX 293 Epidemics, New York, 70 Epidemiology, history of, 28, 52 Epileptic convulsions, 83 Epincijhrin treatment, 175 Equinus deformity, treatment of, 195 Eruptions, 130 Essential paralysis, 73 of children, 73 Examination of muscles, 204 Facial nerve, 112 paralysis, 150 Fatigue, 180 Feliling's test, 143 Fever, 77 Fibrillary twitching, 78, 88 Fifth nerve, 109 First nerve, 108 Flea, 58 Floors, lower, 67 Fluid, cerebrospinal, 138 Fly, passive carrier, 51 Foam test, 141 Food, 60 Foot, 118 Foreign death-rates, 158 Fourth nerve, 108, 109 Frequency, 53 of cranial nerve afTection, 114 Fruit, 60 Froin's reaction, 143 G Gastro-intestinal cases, 79 symptoms, 78 tract, 132 General suggestions for prevention, 260 Geographical distribution, 53 GlobuUn test, 139 Glossopharyngeal nerve, 113 Glycosuria, 132 Gordon's reflex, 267 Gram-negative baciUi, 48 Guinea-pig and virus, 50 H Headache, 125 puncture, 137 Health department nurses, 257 Heart, 132 Hei-pes, 130 Hexamethjdenamin, 254 Hip, 118 deformities, treatment of, 197 Histological changes, 34 history of, 26, 27 Holt-Howland classification, 74 Hosi)ital, removal to, 25() visits of parents to, 258 Hydrotherapy, 181 Hygienic conditions, 67 Hyperextension of knee, 197 Hypoglossal, 114 Hysteria, 148 Idiocy, amaurotic family, 150 Idiopatliic paralysis, 73 Immune bodies, length of time persist- ing, 172 Immunity, 69 test, 144 Incubation period, 122, 255 Infant death-rate, 72 Infantile paralysis, 73 spinal paralysis, 73 Infection, intra-uterine, 63 length of, 72 Information for the public, 260 Insects, 58 virus in, 51 Intercostals, paralysis of, 106 Intra-uterine infection, 63 Intravenous injection of serum, 172 Isolation, 255 Joint swelhngs, 130 Kernig's sign, 79, 88, 145 Knee, 118 deformities of, treatment of, 196 hyperextension of, 197 Knock-knees, ti-eatment of, 197 Krause's classification, 74 Landry's paralysis, 74, 89 Laryngitis, 147 Larynx, 113 Late cord affections, 163 Leukocj'tosis, 131 Lice, 58 Liver, changes in, 39 Localization of reflexes, 266 Lower floors, 67 294 GENERAL INDEX Lumbar puncture, 28, 135 treatment by, 166 Lumbosacral plexus, 275 Lymphoid tissue, changes in, 39 M MacEwen's sign, 79 Massage, 181 Measuring for orthopedic apparatus, 189 Medulla, pathology of, 35 Mendel's reflex, 267 Meningeal form, 74, 87 Meningismus, 149 cerebrospinal fluids in, 143 Meningitis, cerebrospinal, 149 tuberculous, 148 Mental condition, 77 deficiency, 150 degeneration, 85 Micrococci, cultivation of, 47 Microorganism causing poliomyelitis,44 Milk, 60 Monkeys, disease in, 29 virus in, 49 Moral deterioration, 85 Morning paralysis, 73 Mortality and age, 158 Mtiller's classification, 75 Muscles, changes in, 37 examination of, 204 neurotization of, 202 test, spring balance, 247 training, 204 Myelitis of the anterior horns, 73 transverse, 150 Myogenic paralysis, 73 N Nasal washings and virus, 43 Nativity, 62 Neck, paralysis of, 103 Negroes, 62 Nephritis, 147 Nerves, first, 108 eighth, 113 eleventh, 113 fifth, 109 fourth, 108 ninth, 113 second, 108 seventh, 112 sixth, 108 tenth, 113 third, 108 transplantation of, 202 twelfth, 114 Neuritis, peripheral, 151 Neurotization of muscles, 202 New York City Department of Health circular, 260 classification, 75 epidemic, 70 Ninth nerve, 113 Noguchi and Flexner organism, cultiva- tion of, 44 Nonparalytic form, 76 Normal horse serum, 174 human serum, 174 Nose, 67 Nurse, 259 health department, 257 requirements for, 257 Nystagmus, 126 Ocular nerve, 108 Oculomotor nerve, 108 Old cases, pathology of, 36 Olfactory nerve, 108 Onset, 76 mental condition in, 77 pain in, 77 of paralysis, 93 symptoms of, 76 without prodromata, 122 Operative treatment, 195 summary of, 202 Oppenheim's reflex, 267 Orthopedic apparatus, measuring for, 189 treatment, 185 Pain, 77, 79, 127 at onset, 77 disappearance of, 129 treatment of, 165 Pandy's test, 139 Paralysis, abdominal, treatment of, 198 acute fatty atrophic, 73 infantile, 73 spinal, 73 atrophic, 73 back muscles, 103 Bell's, 112, 150 bulbar, 115 congenital spastic, 150 delayed, 122 dental, 73 diagnosis of, 93 diaphragm, 104 diphtheritic, 151 distribution of, 98 GENERAL INDEX 295 Paralysis during dentition, 73 essential, 73 of cliildrcn, 73 facial, 150 {!;astrocnemius, treatment of, 187 idiopathic, 73 infantile, 73 spinal, 73 intercostals, 106 morning, 73 myogenic, 73 neck, 103 onset of, 93 regressive, 73 teething, 73 thoracic, 106 Paralj-tic brace, 187 cases, 95 Parents, visits of, to hospitals, 258 Passive carriers, 51 Patheticus, 108 Pathology, 32 history of, 26 Patient, care of, 259 return of, 258 Peabody, Draper and Dochez classifica- tion, 75 Peripheral neuritis, 151 Peyer's patches, 39 Physicians, requirements for, 257 Physiological reminders, 265 Placards, 256 Pneumogastric, 113 Pneumonia, 132 Poliomyehtis anterior, 73 acuta, 73 epidemics of, 277 in 1916, 281 in United States since 1910, 280 Polyneuritic form, 74, 88 Pons, pathology of, 35 Posterior root lesions, 35 Pott's disease, 150 Preparation of serum, 171 Preparalytic stage, 76 Prevention, 253 of deformity, 179 general suggestions for, 260 Prognosis, 157 Progressive inuscular atrophy, 163 Prophylaxis, 253 Prostration, 124 Pseudoneuritis, 88 Pseudoparalysis, 147 Ptosis, 109 Public, information for, 260 Pulihcity, 72 Puncture headache, 137 lumbar, 135 Q Quarantine, 255 State, 263 Rabbits, virus in, 50 Rabies, diagnosis from, 125 Race, 62 Railroads, 61 Reaction of degeneration, 156 Recovery, condition after, 161 Recurrences, 122 Reflexes, 126 Babinski's, 267 Gordon's, 267 localization of, 266 Mendel's, 267 Oppenheim's, 267 Regressive paralysis, 73 Relapses, 122 Reminders, anatomical, 265 physiological, 265 Remission of symptoms, 122 Removal to hospital, 256 Renovation, 257 Requirements for nurses, 257 for physicians, 257 Respiratory failure, treatment of, 165 symptoms, 132 Return of patients, 258 of suspects, 258 Rickets, 148 Salads, 60 Scohosis, treatment of, 188 Scurvy, 147 Season, 55 Second attacks, 123 nerve, 108 Segments of spinal cord, 267 Sensory disturbances, 129 nerves, distribution of, in skin, 272 Serum, antipoliomyehtis horse, 173 duration of, 171 normal horse, 174 human, 174 intravenous injection of, 172 preparation of, 171 subcutaneous injection of, 172 therapj^ 167 treatment, summary of, 175 Seventh nerve, 112 Sewage, 61 Sex, 63 Shortening, treatment of, 187 296 GENERAL INDEX Shoulder, 118 Sign, Babinski's, 88 Brudzinski's, 79, 145 Kernig's, 79, 88, 145 MacEwen's, 79 Silk ligaments, 200 Sixth nerve, 108 Skin, dry, 130 Social conditions, 67 Spasmophilia, 148 Spastic paralysis, congenital, 150 Special features, 122 Speech disturbances, 126 Sphincters, 107 Spinal accessory, 113 cord, pathology of, 33 segments of, 267 fluids, characteristics of, 142 chemical studies of, 143 form, 74, 97 Spleen, changes in, 39 Spodiomyehtis, 73 Spodomyehtis, 73 Spring-balance muscle test, 247 Stable fly, 51, 58 State quarantine, 263 Stomoxys calcitrans, 51, 58 Streptococci, 48 Stupor, 124 Subcutaneous injection of serum, 172 Superior oblique, 109 Surroundings, care of, 259 Suspects, return of, 258 Sweating, 78, 130 Swelhngs of joints, 130 Symptomatology, 122 Symptoms of onset, 76 respiratory, 132 Synonyms, 73 Tache cerebrale, 88, 130 Tachycardia, 113 Taste disturbances, 126 Tay-Sachs' disease, 150 Teeth, 68 Teething paralysis, 73 Temperature, 123 Tenderness, 127 disappearance of, 129 treatment of, 165 Tendon fixation, 200 shortening, 200 transplantation, 198 Tenodesis, 200 Tenth nerve, 113 Tephromyelitis, 73 Terminal disinfection, 257 Termination of case, 260 Test for albumin, 139 chemical, 139 Fehling's, 143 foam, 141 for globuhn, 139 immunity, 144 Pandy's, 139 spring-balance muscle, 247 Tsuchiya's, 139 Tetany, 148 Third nerve, 108 Throat, 67 Thrombosis, cerebral, 149 Tonsils, 67 Total count, 138 Training of muscles, 204 Transient ataxia, 83 Transmission, 56 to animals, 49 experiments, 29 Transverse myelitis, 150 Travel, 260 Treatment, 164 of abdominal paralysis, 198 of acute stage, 164 adrenalin in, 175 of carriers, 254 of convalescent stage, 177 drugs in, 166 of dyspnea, 165 electricity in, 183 epinephrin in, 175 of equinus deformity, 195 of gastrocnemius, 187 by heat, 182 hexamethylenamin in, 254 of hip deformities, 197 of hyperextension of knee, 197 of knee deformities, 196 of knock-knees, 197 by lumbar puncture, 166 by massage, 181 operative, 195 orthopedic, 185 of pain, 165 paralytic brace in, 187 of respiratory failure, 165 of scoUosis, 188 serum therapy in, 167 of shortening, 187 of tenderness, 165 Tremor, 79, 126 Trigeminal, 109 Tsuchiya's test, 139 Tuberculous meningitis, 148 Twelfth nerve, 114 Twitching, 126 fibrillary, 78, 88 Type of child, 68 GENERAL INDEX 207 Uremia, 147 Urine, 131 Utensils, care of, 259 Vasomotor disturbances, 79 Vegetables, 60 Virus and artificial conditions, 40 in cerebrospinal fluid, 41 choroid plexus and, 42 cultivation of, 44 drying of, 41 in guinea-pigs, 50 in human body, 41 importation of, 52 in insects, 51 in monkeys, 49 nasal washings and, 43 Virus, nature of, 40 neutralization of, 43 outside the Ijody, 43 persistence of, 43 portal of entry of, 32 in raljbits, 50 reaction to antiseptics, 40 Visits of parents to hospitals, 258 Vomiting, 78, 132 cyUc, 147 W Watercourses, 61 Wickman's classification, 74 Zappert's classification, 74 DUE DATE MAY 93199^ JUM 1 ^ 1= 93 ft i«« CI n ^^3 r ^A^ la^' '''' ■.:"i '.. 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