THE LABORATORY DIAGNOSIS OF POLIOMYELITIS. JOSEPHINE B. NEAL, A. B., M. D., Chief, Meningitis Division, Bureau of Laboratories, Department of Health, New York City. Read before the Laboratory Section, American Public Health Association, Cincinnati, Ohio, October 26, 191(1. T HE Meningitis Division of the cases is indispensable. The develop- Department of Health was ment of experimental poliomyelitis established six years ago in in a monkey inoculated with an emul- order to afford to the physicians of the sion of the brain and cord of a patient city of New York expert assistance in who has died of the disease, makes the the diagnosis and treatment of men- diagnosis. But if a monkey develops ingitis. Since 1910 we have held con- poliomyelitis after being inoculated sultations in nearly 1,600 cases, pre- with the washings of the nose and senting a great variety of meningeal throat of a case, without the history conditions. These have included tu- and clinical findings, one cannot be berculous meningitis, purulent men- sure that it is not a carrier rather than a ingitis of all kinds (meningococcic, true case. Moreover, on account of pneumococcic, streptococcic, influen- the varying susceptibility of monkeys zal, staphylococcic); meningism in a and the small amount of virus present variety of diseases, especially pneu- in the nose and throat washings, such a monia, gastro-enteritis and other acute large number of negative results are infections in children; many rarer obtained that the method would be conditions, such as brain abscess, brain unsuitable for routine diagnosis, even tumor, syringomyelia, etc.; and over if it were not so expensive and did 500 cases of poliomyelitis, alone, 70 of not take so long for results to develop. which occurred before the incidence These objections apply also to the of the recent epidemic. During the neutralization test. This test consists epidemic, doubtful cases have been in incubating a mixture of blood serum reported to us for diagnosis. As our from a suspected case with a known work in the past had consisted in a active virus. This mixture is inocu- careful clinical study of the cases, lated intracerebrally in one monkey combined with various laboratory pro- and the virus alone in a control. The cedures, especially the examination of presence of antibodies in the serum the spinal fluid, which we withdrew if is demonstrated if the control monkey the conditions seemed to warrant it, becomes infected while the other we had had experience that was par- monkey does not. A further objec- ticularly valuable to us in diagnosing tion to this method lies in the fact these doubtful cases, for there is no that the serum of many people known purely "laboratory diagnosis" of polio- not to have had a recent attack of myelitis during the life of the patient poliomyelitis shows the presence of though the laboratory aid in doubtful antibodies. Other blood examinations 144 Laboratory Diagnosis of Poliomyelitis 145 are of little or no value. The count not been collected and there is yet shows, as a rule, a leucocytosis and a considerable work to be done in study- polynucleosis, which is true of most ing the cytology of smears from the infections with which poliomyelitis centrifuged fluids. Not wishing to may be confounded. The complement give incomplete data nor to burden fixation has so far been unsuccessful. you with unnecessary details, I will The examination of the urine has give the more general facts and con- no diagnostic importance so far as is clusions from the data that I have known at present. At first, it shows studied. the characteristics of an acute febrile The spinal fluid in poliomyelitis is condition, later in the paralyzed cases, usually increased in amount and es- the end reaction of the products of capes under pressure. It is clear or muscle degeneration. Clinically, it slightly hazy in appearance and some- should be noted that in the severe times shows the febrin web formation cases there is often a retention of which was formerly considered path- urine, in the very severe cases oc- ognomonic of tuberculous meningitis. casionally a suppression. Recently, attention has been called to The examination of the spinal fluid the "ground glass" appearance (or is the most valuable laboratory aid in a slight haziness seen in the fluid when the diagnosis of poliomyelitis, but even viewed by strong transmitted light) here, there are no pathognomonic as being of help in diagnosing polio- findings, as for example, the infecting myelitis fluid. This appearance is organism in a purulent or a tuber- found in the fluids containing the larger culous meningitis. It is by ruling number of cells. When the cells are out other conditions that it is of value fewer, I, personally, should hesitate and it is of the greatest service only to say from the macroscopic appear- when correlated with a careful clinical ance whether or not the cells are in- study of the case. (Of course no creased. Moreover, this appearance diagnosis is easier clinically than that is also seen in the fluids of tuberculous of poliomyelitis with a frank flaccid meningitis, in early purulent meningi- paralysis, but few diagnoses are more tides with a slight cellular reaction and difficult, clinically, than the non- in normal fluids where there is a small paralytic and atypical cases, which amount of blood present. In view of are so important from the standpoint these facts, the "ground glass" ap- of epidemiology.) pearance is of little more significance During the recent epidemic, we than the increased quantity. If a bed have examined over 1,800 fluids from side examination of the fluid is neces- both the paralyzed and non-paralyzed sary, one should go with the proper cases, nearly 500 of these being from equipment to make a fairly reliable cases which we had seen in their homes. examination. The data from this material has not In poliomyelitis, the spinal fluid yet been entirely arranged as certain shows evidence of an inflammatory facts relating to our own cases have reaction-there is a varying increase in 146 The American Journal of Public Health the cells and in the albumin and globu- any relation to the prognosis of the lin. In a few cases these evidences case. We have made a fair nuniber of of an inflammatory reaction are well cell counts in connection with the marked; in most cases they are moder- work and we find that, on the whole, ate; while in a few cases, at the other the two methods check up fairly well. extreme, they are so slight and the From these stained sediments we also fluid so nearly approaches normal that estimate the percentage of mono- it is difficult to make a definite state- nuclears and polymorphonuclears and ment in regard to the findings. The note the presence of endotheliod and reduction of Fehling's in these fluids polyform cells. The presence or ab- is practically always as prompt as in sence of bacteria is also noted. Cul- normal fluids. tures are made from all specimens. In The technic which we employ in the case of uncontaniinated polio- examining spinal fluids is as follows: myelitis fluids, they have been uni- All clear or slightly cloudy fluids formly negative. are centrifuged for an hour at high The chemical tests that we use are speed. From the sediment, spreads the nitric acid ring test for albumin are made, taking care to use as nearly and the Noguchi butyric acid test for as possible, the same area on the globulin. The albumin and globulin different slides. The sediments of practically always run parallel, but clear fluids are stained by the Ziehl- they serve as a check on each other. Nielsen method for the tubercle ba- The small amount of albunmin and cillus-the sediments of slightly cloudy globulin present in nornmal fluids is fluids for both the tubercle bacillus marked-. The signs, +, +1, ++, and by the Gram method. Smears ++ +, + + + +, represent in- from the poliomyelitis fluids were also creasing amounts and serve as a made for special blood stains in order rough quantitative estimnation. The to study the cells. This work has not presence of glucose is tested by using been completed. From this stained an equal amount of Fehling's solution sediment, we can estimate the in- and spinal fluid and it is marked with crease in cells as slight, moderate, regard to the speed and the amount of great, or very great. We do not feel reduction as -, , +,++.++±, +++. that the exact number of cells has The globulin reaction and the reduc- more than an academic interest. The tion of Fehling's should not be read cell count in poliomyelitis and tuber- for at least half an hour. culous meningitis, while on the aver- Taking up these points somewhat in age higher in the latter, overlaps for detail, let us first consider the cytology. so wide a range as to render the differ- The increase in cells varies very greatly ential diagnosis by this point most un- both in different cases and in the stage reliable. Moreover, while some claims at which the puncture is done. Our to the contrary have been made, it is counts have varied from slightlv above not our impression that the number normal, 15-20 to 350-400. The counts of cells in poliomyelitis fluids bear tend to fall off after the first N-eek and Laboratory Diagnosis of Poliomyelitis 147 by the end of the second week have We will now consider the differential fallen to practically normal in nearly diagnosis of poliomyelitis fluids. all cases. The slightly cloudy fluids must be The cells usually show a prepon- differentiated from those of early derance of mononuclears but in a few cases of purulent meningitis and from instances there is over 50 per cent. the slightly cloudy fluid that occa- of polymorphonuclears. It has been sionally occurs in tuberculous men- stated that early in the disease ingitis. The clear or practically clear there was an excess of polymorpho- fluids, from rare early cases of a nuclears, which later was replaced by purulent meningitis, tuberculous men- mononuclears. In the large number ingitis, syphilis of the central nerv- of early fluids that we have examined ous system, especially acute syphilitic on the second, third, and fourth days, meningitis, and meningism. Other the polymorphonuclears-out of a rarer conditions might be mentioned, special series of about 400 fluids in but these are the most important. only 3 cases, occurring on the third, In early cases of purulent meningi- fourth, and fifth days respectively. tis, the spinal fluid shows a varying We feel, therefore, that the poly- degree of cloudiness, except in very morphonuclears represent a special rare instances, when it may be clear. type of reaction-and is not charac- A greater increase in albumin and teristic of a stage of the disease. globulin is usually found here than Often, even in fresh fluids. the cells are occurs in poliomyelitis, with a poorer so degenerated that it is difficult to reduction of Fehling's solution. The classify them. There are large mono- cells in these fluids of purulent nuclear cells that seem to be endothe- meningitis are 90 per cent. or more liod in type that seem to us to occur polymorphonuclears, and the etio- more frequently in poliomyelitis than logical organism is always found in other conditions. The so-called except in the mildest cases. In cer- polyform cells are also found. We tain mild cases of meningitis-prob- hope to study the various types of ably of the epidemic variety-the cells more carefully a little later. meningococci may never be positively The albumin and globulin are usu- demonstrated in the fluid. In purulent ally slightly to moderatelv increased. meningitis, due to other organisms, In 141 fluids, 99 were marked + or these practically always appear later. + 1; 36, + + or + + 1; 5, + + +; In one instance only, we have seen a and 1, + + + +. The increase in clear fluid from an early case of epi- albumin and globulin persists after the demic meningitis of about eighteen cell count has returned to normal. hours' standing. Although the cellu- Fehling's, as has been stated before, lar reaction was so slight, the meningo- is practically always well reduced. coccus was demonstrated to be present The fluids that show a poorer reduc- in the fluid by smear and culture. tion are usually those with the larger The fluid in tuberculous meningitis amount of albumin and globulin. most nearly resembles that of polio- 148i The American Journal of Public Health myelitis. It is practically always clear found in a large series of cases have with a cellular increase consisting fallen mainly into three groups: fluids largely of mononuclears, though in from cases with prolonged and severe very acute cases it may be distinctly convulsions; fluids in severe whooping- cloudy with an excess of polymorpho- cough; and fluids removed just prior nuclears. Fortunately, in these cases, to death. In these cases there have the tubercle bacillus is usually easy to sometimes occurred an increase in demonstrate. The number of cells cells, or in albumin and globulin or in per cubic millimeter is usually greater both. In convulsions, there is prob- than in poliomyelitis; the increase in ably oedema, in whooping-cough mi- albumin and globulin is more marked, nute hemorrhages, and just before and the reduction of Fehling's is not death circulatory changes to account so good. for it. In rare instances when clinical Lange's colloidal gold test has been signs are confusing and when the used to some extent by workers to results of the cellular examination whom we have given specimens of and chemical analysis are indefinite, fluid and it would seem that it may be and it is impossible to demonstrate helpful in differentiating the fluids the tubercle bacillus in the fluid, a of poliomyelitis from those of tuber- positive diagnosis must wait upon the culous meningitis and from the fluids results of animal inoculation. of meningism which are not normal in The fluid of an acute syphilitic character. meningitis closely resembles the fluid Two rare types of spinal fluids of a poliomyelitis, and the clinical sometimes occur in poliomyelitis when signs are also confusing. The Was- the hemorrhagic process has been sermann reaction is the best method more than usually severe. The first of differentiating the two conditions. of these is of the true hemorrhagic Of course, a positive Wassermann character, the red blood cells being would not rule out a poliomyelitis in evenly diffused throughout the field. an old syphilitic condition, but this, When collected in successive tubes the combined with the clinical condition specimens are all homogenous, show- and the progress of the case, makes one ing no change in the intensity of the reasonably sure of the diagnosis. It hemorrhage. This serves to differen- was suggested at first that the products tiate it from bloody fluids obtained by of degeneration present in the spinal the accidental puncture of a vein. fluid of poliomyelitis cases might give Evidence of an older hemorrhage a non-specific Wassermann reaction. occurs in the second of these rarer Repeated tests have proved this not fluids, which, having a characteristic true. yellow color and coagulating spon- The fluid of meningism is clear, taneously, illustrates the so-called syn- increased in amount and practically drome of Froin. These fluids occur in always normal in character. The other conditions, and are, therefore, few exceptions to this that we have not pathognomonic of poliomyelitis. Laboratory Diagnosis of Poliomyelitis 149 During the past four months, we Sugar is slightly lower than in the have done some quantitative work on blood-.05 per cent.-.08 per cent. the chemistry of the poliomyelitis All show traces of cholesterol. fluids using the micro-chemical meth- In conclusion, I wish to state again ods. This work will be puiblished in that there is no specific laboratory detail later. In brief, I may state diagnosis of poliomyelitis during life that it has been found that the total though the laboratory findings are of nitrogen runs 20-30 mgms. per 100 cc. the greatest possible aid; that physi- Of this total nitrogen about one-half cians can most successfully diagnose is non-protein and about one-fourth is the doubtful cases who have had the urea. most experience with the clinical Creatinin-.5 ngmrn. in 100 cc. study of meningeal conditions of all fluid. kinds, correlated with the laboratory Creatin-.3 mgm. in 100 cc. fluid. study of the spinal fluids.

THE HEALTH BULLETIN. The health officer has ever had a variety of was sorely puzzled as to its meaning. In other duties. What with controlling foci of infection, cases members of the health staff, excellent in inspecting suspected food, and offensive privies, their special lines of bacteriological or other protecting water supplies, draining swamps, and work, have put things in a way which has thrown determining the fate of sundry noisy and sleep doubt upon their efficacy. Careful editing disturbing fowls of a neighborhood, he has had would have prevented such a misfortune. enough to keep him thinking and acting. Re- On the "popular" side the health bulletin has cently, however, he has had thrust upon him too often accepted the usual notion that in order the business of editor, and often author, of a to appeal to the public, one must highly color, weekly or monthly publication in the interests or in other words, a little, if not considerably, of public and private health. Though pre- exaggerate the facts. If this is the key to the sumably unprepared for such a service the lay mind, the earlier the key is lost the better. health officer has risen to the occasion remark- But the layman is not so stupid. You can fool ably well. him some of the time but not always, and exag- The issuance of a bulletin was not a new thing gerations always react upon their source. for the health department, for a statement of the When it comes to sensational methods in number of cases of this and that disease and the health education the health bulletin cannot hold number of deaths, the number of diagnostic tests a candle to the advertisers of curealls, for they made, and a summary of other work, had often not only have the literary cleverness, but they been published. But the new bulletin deals with have the financial backing. Their reading matters of life and health rather than disease and matter is not sent "to those who desire it" but death-in a word, with prophylaxis. The statis- is spread broadeast and reaches a hundred tics, which we fear were seldom scanned, occupy homes where the health bulletin reaches one. the background in this new literary venture. The competition is most one sided, but truth and In its present (though we doubt its final) stage dignity will prevail even Qver lies. The kingdom of evolution, the health bulletin is often an of health, like that kingdom of heaven of which amphibious affair, intended for both the pro- it is an essential part, is like a grain of mustard fession and the public, and for this and other seed and will surely grow and increase. Let us reasons, appealing less than it might, to either. avoid doing anything that will (lelay that growth. The material intended for physicians is often of The health bulletin is an aid toward furthering a nature perplexing to the laity. In fact we the kingdom, but let it be worthy of its cause.- have seen such material so poorly worded or Editorial, Newl Y'ork Medical Journal, January badly edited that the medical reader himself 27, 1917.