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.