POLIOMYELITIS AND POLIO-ENCEPHALITIS. 151 Postgrad Med J: first published as 10.1136/pgmj.2.22.151 on 1 July 1927. Downloaded from coryza, or gastro-intestinal symptoms such as vomiting and diarrhoea. The lymphatic glands are POLIOMYELITIS enlarged. The temperature rises, often ranging AND POLIO-ENCEPHALITIS.* between 101° and 103°F., and there is general malaise often accompanied by profuse sweating. BY In some cases both local and general symptoms are E. A. COCKAYNE, M.D. OXF., F.R.C.P. LOND., so slight that they may be overlooked and the PHYSICIAN TO THE MIDDLESEX HOSPITAL; PHYSICIAN rise of temperature may be very small. After TO OUT-PATIENTS, HOSPITAL FOR SICK CHILDREN, lasting from one to four days the illness may end GREAT ORMOND-STREET. at this stage. If it continues headache, drowsiness POLIOMYELITIS, like other specific fevers, has its and irritability, pain and stiffness in the back, special age and seasonal incidence; it is commonest accompanied sometimes by twitching of the in the late summer and early autumn, and the limbs or retraction of the head, may develop, and majority of its victims are children between the these indicate involvement of the meninges. ages of 1 and 5 years. The earliest symptoms are Hyperssthesia of skin and muscles may also be constitutional, malaise and fever, and in some prominent. Then if the grey matter of the central cases the involvement of the nervous system, to nervous system becomes infected, weakness, paresis, which it owes its name, never occurs. Such and paralysis of muscles develops. Paralyses cases are usually regarded as abortive, but in may appear to be dramatically sudden, but my opinion this view is not the correct one. It careful observation has shown that in reality they is generally admitted that at the times when the develop gradually and increase during a period disease becomes epidemic, infectivity and virulence of from one to four days. In the great majority increase.together. The mere fact that it is epidemic of cases the spinal cord is the only part affected, and proves the increase in infectivity, and the fact even then the lumbar or cervical enlargement is that adolescents and adults, who are spared as a often the only part of it that suffers. The lumbar rule, fairly often contract the disease at such times cord is attacked from two to four times as often and that deaths are not uncommon shows that the as the cervical. The acute inflammation of the virulence also is greater. cord persists for some time, perhaps for a month, The so-called abortive cases are and during this period tenderness and pain on

recognised copyright. comparatively easily in epidemics, especially those movement may be noticed. As they diminish in country districts, and it has been estimated that the weakness of muscle, which is sometimes they form from 50 to 70 per cent. of the total widespread, gradually disappears. Paretic muscles number of cases. It is reasonable to suppose that recover later, and finally certain groups of muscles when virulence is less they must form an even remain completely or partially paralysed. In the larger proportion, though there is so little that upper limb those nearest the trunk suffer most is distinctive in the symptoms that they pass for frequently, the scapular muscles and the deltoid the most part unrecognised. If this be admitted, especially. In the lower limb the quadriceps, http://pmj.bmj.com/ surely we must look on the kind of case which is tibialis anticus, and peronei are most often commonest as typical and regard the paralyses, affected, and next to them the muscles of the when they occur, as a complication. This view hip. The small muscles of the hand and foot of the disease makes it easier to understand are very rarely paralysed. Combinations of arm the mode of spread. Cases with paralysis often and leg paralyses are quite common, and in the appear scattered over a district in such a way that severer cases muscles which usually escape may no direct contact of one with another can have suffer, especially those of the back. Sometimes an happened. Those with slight constitutional unusual part of the cord is alone affected, and on September 28, 2021 by guest. Protected symptoms must often be the missing links between complete or partial paralysis of the muscles 'of the paralytic ones allowing a direct spread from the neck, back, or abdomen results, but such one infected individual to another. Carriers also paralyses are more often seen in combination with are important factors in the dissemination of the the commoner ones. It is often stated that only virus. The immunity conferred by these trifling the anterior horn cells are destroyed, but this is attacks also serves to explain the limited number untrue. Sensory symptoms are met with, but are of paralytic cases met with in epidemics, especially commonest in severe cases where they are likely in big towns. Except in country districts many to be overlooked, and in any case cannot be of the susceptible individuals become immunised recognised in very young children. in this way. Purely vegetative forms are rare, but the ganglion DESCRIBED. cells of the sympathetic fairly often suffer with those THE DISEASE of the anterior horns and lead to a blue, cold, and After this preliminary discussion I will give a dry condition of the skin, retention of urine, brief account of the disease. Infection takes place disturbances in the function of the stomach through the nasopharyngeal mucous membrane, and intestine, and ptoses of the viscera. and after an incubation period averaging nine or Very rarely the destruction of the nerve-cells of ten days the illness sets in, often with tonsillitis, the cord is so intense and local that the clinical * A Lecture delivered at the Hospital for Sick Children. signs are those of a transverse myelitis. Another 152 POLIOMYELITIS AND POLIO-ENCEPHALITIS. Postgrad Med J: first published as 10.1136/pgmj.2.22.151 on 1 July 1927. Downloaded from uncommon but well-defined clinical variety is that be an excess of cells, though fluid under pressure, in which the virus steadily advances along the but normal in all other respects, is commoner. cord from below upwards, and most of the cases Symptoms peculiar to various fevers may help to recorded under the title of Landry's ascending separate them from poliomyelitis; influenza offers paralysis are of this nature. Recrudescence with the greatest difficulties. The character of the a fresh rise of temperature, sometimes accompanied cerebro-spinal fluid affords a ready means of by further paralyses, is so uncommon that it only separating it from most forms of meningitis. The requires a passing mention. fluid in tuberculous meningitis is most like it, but Sometimes instead of, or in addition to, the differs in the decrease in sugar and chlorides and grey matter of the cord, that of the medulla, mid- in the fine cobweb coagulum in which tubercle brain, cerebellum, or cerebrum is attacked, and bacilli can often be found by careful searching. in each case a different clinical picture is presented. The onset of the disease is more insidious, and the In the bulbar form facial and hypoglossal paralyses progress steadily down hill, transient pareses of are commonest; oculomotor paralyses are much cranial muscles are common, and tubercles in the rarer. The midbrain forms result in a variety of choroid and papillcedema, which never occurs signs including tremors, choreiform movements, and in poliomyelitis, help to differentiate the two nystagmus. Acute ataxia is caused by cerebellar conditions. polio-encephalitis. When the cerebrum is the site of In spinal forms, when paralyses are severe and the disease, headache, stupor, convulsions, spastic local, there should be no difficulty in diagnosis, palsies, hemiplegic or diplegic, are the outstanding though on two occasions I have known them to features, but they are usually associated with be mistaken for football injuries in spite of fever bulbar palsies. Death is usually due to destruction and malaise. When there is not more than moderate of the cells in the medullary nuclei, particularly paresis the nature of the disease often escapes those of the respiratory and cardiac centres, less recognition until the patient gets up, and a diagnosis often to paralysis of the muscles of respiration, the of influenza or acute rheumatism is given. The intercostals, and diaphragm. In the later stages mistake can generally be avoided by testing the of the disease it may be due to broncho-pneumonia. muscular movements and strength and by examining the reflexes. In the Times recently there was an PATHOLOGY. account of a man, aged 22, who entered the Evanston Hospital with intestinal influenzacopyright. The virus is a filter-passer and has a special accompanied by a creeping paralysis. After affinity for lymphoid and nervous tissue. The 24 hours his respiratory muscles were paralysed, meninges are infiltrated by lymphocytes and in the but he was kept alive for 108 hours by artificial grey matter there is a dense perivascular infiltration and remained by lymphocytes with minute haemorrhages and respiration conscious to the end. destruction, followed by phagocytosis, of ganglion This reads like a case of mistaken diagnosis. The cells. The cerebro-spinal fluid is under slight man probably had poliomyelitis with gastro- intestinal onset followed by complete paralysis of http://pmj.bmj.com/ pressure, clear or opalescent with excess of cells, the at first polymorphonuclear leucocytes and later respiratory muscles. lymphocytes. The number of cells per c.mm. Transverse myelitis is so rare in children that its varies from 40 to 2000, but the lower figures are the simulation by poliomyelitis is unlikely to deceive more usual. Glucose and chlorides remain normal, the clinician, though it may do so in the case of but globulin is present in excess. The character of an adult. Diffuse paretic forms resemble multiple the neuritis, but absence or slightness of sensory cerebro-spinal fluid is important and may be symptoms distinguish it from all except post- the only means of diagnosing an obscure case. diphtheritic paralysis. Palatal paralysis, paralysis on September 28, 2021 by guest. Protected For clinical purposes cases may be divided into of accommodation, and of the external rectus, and the following groups, but combinations between one irregularity of the heart are common after diphtheria or more of them are so common that the classifica- and very rare in poliomyelitis. The cerebro-spinal tion is somewhat arbitrary. 1. Uncomplicated. fluid is normal, in post-diphtheritic neuritis. 2. Meningeal. 3. Spinal: (a) paralytic; (b) Polio-encephalitis is most likely to be mistaken for diffuse paretic; (c) simulating transverse myelitis; encephalitis lethargica, and here the cerebro-spinal (d) Landry's ascending paralysis. 4. Bulbar. fluid affords no help. In poliomyelitis the onset 5. Midbrain. 6. Cerebellar. 7. Cerebral. is sudden and progress stops after about four days, whereas in encephalitis lethargica the onset is DIFFERENTIAL DIAGNOSIS. often gradual and progress is indefinitely prolonged. Uncomplicated cases are seldom recognised except Lower motor neurone lesions are never met with in in an epidemic. They are generally mistaken for the latter but often accompany the upper motor influenza or gastro-enteritis. Meningeal cases are neurone lesions of the former. In sporadic cases, difficult to differentiate' from specific fevers such when the spinal cord escapes, it must be admitted as influenza with meningismus and from other that the two diseases may be indistinguishable. forms of meningitis. If the cerebro-spinal fluid Polio-encephalitis is, however, the rarer at present. is clear and without excess of cells poliomyelitis Many years ago I remember seeing two children in can be excluded, but in meningismus there may one family attacked by polio-encephalitis within a FUNCTIONAL NERVOUS DISORDERS OF THE HEART. 153 Postgrad Med J: first published as 10.1136/pgmj.2.22.151 on 1 July 1927. Downloaded from few days of one another. The little girl had paralysis bed the muscles must be kept relaxed. Massage of the right side of the face and neck and her and electrical stimulation should be avoided during bigger brother had acute ataxia. In both cases the this period; the muscles can be kept slack by means onset was sudden; the girl remained paralysed, of pillows or sand-bags. If these fail to hold them but the boy made a quick and complete recovery. in the neutral position, as they may, especially The flaccid paralysis of the neck muscles in the when both flexors and extensors are affected, girl and the sudden onset and short course of the splints must be used, but care must be taken to illness in the boy distinguished either from make them light and not to interfere with the blood- encephalitis lethargica, and illustrate two of the supply. When the patient is up the limb must be points in differential diagnosis which I have just kept very warm by means of an extra wool stocking mentioned. for the lower limb or an armlet for the upper limb. When a case arises during an epidemic it is Gentle massage should be carried out twice daily important not only to treat the sufferer but to to help in keeping the muscles well nourished, but prevent the infection spreading to others. This is even at this period of the illness electrical stimula- done by isolating the patient and the contacts. tion is better avoided. It may do harm in unskilful The virus in carriers probably soon begins to lose hands, and at the best is no better than massage. virulence and infectivity and most of the danger Plasters are only mentioned to be condemned. from this source is over in a fortnight, though Splints must be worn as far as possible continuously it has been proved that the virus can live for six and must be designed with care. The exact position weeks in the nasopharynx. The value of local in which the limb must be kept depends on the disinfectants is unknown, but for the sake of groups of muscles affected and the degree to which themselves and others contacts should use nasal they are affected. Particular care must be taken sprays or douches, and gargles. Potassium when both flexors and extensors are weakened. In permanganate and hydrogen peroxide, which kill every case the. splint must be specially adapted to the virus in vitro, are perhaps the best disinfectants. the condition found, and the object aimed at is the prevention of any stretching of the affected muscles. TREATMENT. It is permissible to stretch them for a brief period, Though it is the ideal time little can be hoped for but not to allow any lasting pull on them. It is from the treatment of cases before paralysis sets in. often said that no improvement takes place after Diagnosis during the period of constitutional two years and very little after the first year, but I copyright. symptoms is almost impossible except at a time have seen considerable progress take place during when the disease is epidemic, and in any case the the third year. If nutrition and relaxation of the interval between the onset and the occurrence of muscles are properly attended to deformities will paralyses is very short. The only drug which has not develop and the operations designed to correct any experimental evidence in its favour is hexamine. them will not be necessary. Attacks in monkeys, which are usually fatal, were aborted or made milder when hexamine was given http://pmj.bmj.com/ early enough. Its effect on man has been tested too seldom in suitable cases for much to be said about FUNCTIONAL NERVOUS its value, but it deserves a thorough trial. Hurst DISORDERS OF THE HEART.* has suggested that the dose should be large, up to 60 or 100 gr. a day, and no ill-effects are to be BY anticipated if the urine be kept alkaline by means F.R.C.P. of and frequent doses of sodium bicarbonate and R. TRAVERS SMITH, M.D. DUB., IREL., big CONSULTING PHYSICIAN TO THE WEST MIDDLESEX HOSPITAL; on September 28, 2021 by guest. Protected potassium citrate. Hexamine only breaks down in PHYSICIAN TO THE MILLER GENERAL HOSPITAL, S.E. an acid medium, and its activity in the alkaline (Concluded from p. 139.) cerebro-spinal fluid is difficult to understand. Perhaps the virus of poliomyelitis makes the fluid IN the first portion of this address, certain in contact with it acid, and so causing the liberation functional diseases of the heart were discussed- of formaldehyde leads to its own destruction. If namely, Fainting, D.A.H. and Tachycardia, and so one can understand the need for massive doses. Heart Pain. We now deal with Arrhythmia, The only other method of treatment at this stage and Breath- is to inject serum from a patient who has had the Giddiness, Night Starts, Palpitation, disease recently, but this is unlikely to be procurable lessness. except during an epidemic. 4. Arrhythmia. When paralyses have occurred, absolute rest in Certain forms of this are found preponderating bed is essential, until the inflammation of the cord amongst neurotics as contrasted with non-nervous has subsided. The patient should be kept in bed subjects-assuming organic disease to be excluded till all pain and tenderness have disappeared, for a from both. Anyone who has studied arrhythmia month at least. After this the important points instrumentally over a long period must have met to bear in mind are to look after the nutrition the sinus form in children, extrasystole in middle of the paralysed muscles and to prevent them * An Address delivered to the Lewisham Division, B.M.A., on from being stretched. Even while the patient is in Dec. 21st, 1926.