period, one an abortive case and two becoming paralyzed on the
day of the first lumbar puncture, gave cell counts of 37, 94, and
113 per cubic millimeter, with 100 per cent, 93 per cent., and
83 per cent, of mononuclear cells respectively, and globulin reac-
tions which fell within normal limits. Finally, in one abortive
case lumbar puncture on the second day after the onset of symp-
toms gave a wholly normal fluid. On the third day the celt
coimt was sixty-two per cubic millimeter with 89 per cent, mono-
nuclears and a s. -{- globulin reaction. On the sixth day the cell
count was fifty-nine per cubic millimeter, all mononuclears, and a
globulin reaction of s. +. On the eleventh day the spinal fluid was
again normal. That this was, indeed, an abortive case of polio-
myelitis was later rendered most probable by a test showing that the
patient's blood serum was capable of neutralizing active virus when
mixed with it and injected intracranially into a monkey.
In these six cases examination of the spinSil fluid gave evidence
which was helpful in making a diagnosis of poliomyelitis before the
onset of paralysis. Similar evidence was afforded by eleven cases
of Lucas and by one of Frissell.*® In none of these twelve cases,.
•Frissell, Jour. Am. Med, Assn., 1911, Ivi, 661.
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106 A Clinical Study of Acute Poliomyelitis.
however, was a large percentage of polynuclear cells found. But it
seems of importance to call attention to the fact that a fluid whose
cytology resembles that found in cerebrospinal meningitis and other
types of purulent meningitis may also occur in the early stages of
poliomyelitis.
The question arises as to whether there is any relation between the
situation and extent of the paralysis or the severity of the disease
and the character of the spinal fluid. Conclusions on this point
cannot be drawn from the number of cases seen by us. It would
seem, however, that in cases in which the paralysis is limited to
arms or to cranial nerves, the lumbar puncture fluid is rather apt
to show less deviation from the normal than where the legs are
involved. This is, however, far from being a constant finding.
Several cases which had acute s)rmptoms (pain, irritability) lasting
for an unusually prolonged period, gave an unusually large and
persistent globulin reaction. Moreover, the disappearance of the
acute symptoms was frequently coincident with a diminution in the
globulin in the spinal fluid. The fatal cases showed nothing in the
fluid on which to base an unfavorable prognosis.
Since the infecting organism in poliomyelitis is too small to
admit of its being seen, even if it is present in the cerebrospinal
fluid, and since the more complicated biological tests have failed to
prove the presence of antibodies in the fluid, the diagnostic value
of examinations of the spinal fluid by simple chemical and micro-
scopic methods must necessarily be merely relative. While in
cerebrospinal meningitis, in tuberculous meningitis, in pneumo-
coccus, influenza, and similar t)rpes of meningitis, one obtains spe-
cific information and is usually enabled to make a positive diagnosis
from an examination of the spinal fluid, the value of the examina-
tion in poliomyelitis is necessarily less direct. Thus, in a fluid con-
taining a high percentage of polymorphonuclear cells, the failure to
find any organisms would certainly be suggestive of poliomyelitis.
The difficulty of differential diagnosis is perhaps greater when one
has a fluid with a lymphocytic cytology. Lucas has discussed at
length the non-specificity of the cytological findings in various
meningeal conditions, and finds a similar cell picture in encephalitis,
poliomyelitis, meningism, tuberculous meningitis, and syphilis of the
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Francis W. Peabody, Oeorge Draper, and A. B. Dochez. 107
-central nervous system. Because, however, the examination of the
spinal fluid in poliomyelitis lacks specific diagnostic value, it would
be wrong to conclude that it was not an important aid In diagnosis,
or that lumbar puncture should not be performed in suspicious cases.
Routine blood examinations and the usual urinary analyses have
â– comparatively rarely a specific diagnostic value. Their greatest use-
fulness consists in helping to rule out certain possibilities, and in
focusing the attention on a narrower group. Within such a group
the blood or urine examination, partly by itself, and partly when
considered with clinical experience, may, by bringing either nega-
tive or positive evidence, be the determining factor which points
towards the correct diagnosis. The value of positive findings in
spinal fluid examinations is undoubted. The value of negative
results in the examination approaches it in importance. Thus in the
-case of poliomyelitis, the failure to demonstrate specific changes in
the spinal fluid should rule out several serious meningeal conditions,
the differential diagnosis of which from poliomyelitis in the pre-
paralytic stage may be most confusing. On the other hand, by the
demonstration of non-specific changes, — for we have seen that by
far the greater number of fluids in poliomyelitis are in one way or
another abnormal, — a host of other conditions which may simulate
incipient poliomyelitis are removed from further consideration.
Among the small group of remaining possibilities, certain charac-
teristic types of fluid, as, for instance, one with a high cell count and
a normal globulin reaction, may be of some value in deciding the
diagnosis. More careful studies of the fluids in conditions other
than poliomyelitis may throw further light on the differential value
•of non-specific fluids. At any rate, when even the non-specific fluid
of poliomyelitis is considered in association with the clinical features
of the case, the diagnosis can probably be made in the great majority
of cases even in the preparalytic stage. The ease and safety with
ivhich lumbar puncture can be performed and the simplicity of the
examination of spinal fluids should make the method much more
widely used than it is at present. The value of any future method
of treatment of poliomyelitis must depend on the possibility of early
•diagnosis, for where the nerve cells have been destroyed, the results
-from any therapeutic measures will be comparatively small.
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108 A Clinical Study of Acute Poliomyelitis.
Conclusions, — The spinal fluid from cases of acute poliomyelitis
during the first few weeks after the onset of symptoms shows, in
the great majority of instances, deviations from the normal.
Fluids taken during the early days of the disease and especially
before the onset of paralysis tend to show an increased cell count
with a low or normal globulin content. At this early stage the poly-
morphonuclear cells may amount to 90 per cent, of the total. Most
fluids, however, show almost exclusively lymphocytes and large
mononuclear cells.
After the first two weeks the cell count usually drops to normal,,
or nearly normal, and there is frequently an increase in the globulin
content. A slight increase in globulin may persist for seven weeks
or longer.
Analogous changes may be found in the spinal fluid of abortive
cases.
All fluids examined reduced Fehling's solution.
The examination of the cerebrospinal fluid in acute poliomyelitis,
while giving, as far as is yet known, no specific diagnostic criteria,,
is of the utmost value as an aid to diagnosis both in preparalytic
and in abortive cases (see tables, pages 109, no, in, and 112).
PROGNOSIS.
Prognosis in poliomyelitis is a complicated problem. If death and
recovery were the only resuhs to be foretold, the matter would be
no more difficult than in other infectious diseases, but there is the
added uncertainty of the paralyses. In a given case seen in the
preparalytic stage, for example, the question at once arises as to-
whether or not paralysis will appear at all. In another case seen
on the first or second day, when there are marked general symptoms-
and when paralysis of a leg or an arm already exists, it is important
to decide whether the process in the spinal cord will probably ad-
vance or not. Finally the question of residual paralysis must be
considered.
The literature of poliomyelitis is fairly rich in mortality statis-
tics, which form, perhaps, the best basis for prognosis as to life or
death. Wickman's series of 868 cases showed a death rate of 16.7
per cent. The figures of numerous other observers are approxi-
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Francis W. Pedbody, George Draper, amd A. B. Dochez. 109
TABLE OF EXAMINATIONS OF CEKEBROSPINAL FLUIDS.
The numerator of the fraction signifies the day of disease; the denominator
is the day of the paralysis. The figure following is the number of cells per
cmm. of spinal fluid. o = normal globulin test; v.s.+= faint precipitate
(above normal) ; s. + = well marked cloud or slightly flocculent precipitate ;
+ = precipitate of large flocculi ; and + += heavy flocculent precipitate with
the butyric acid test
II
xst week.
2d week.
3d week.
4th week.
Sth week.
dth-xoth week.
Z
J 31 V.S.+
Â¥ 7 V.S.+
H 6 V.S.+
2
880 +
627
I.22I +
3
i 7 + +
H5 +
4
i 10 8.+
V- 46 8.+
n S S.+
fi 4 V.8.+
5
It 6 8.+
6
«4 + +
â– f 4 + + +
?| 6 8. +
}|7 8. +
H 2 8.+
7
i 13 + +
a 19 8.+
11 7 9.+
It 6 V.8.+
8
f 37 S.+
i 12 8.+
H90
9
f|30 +
h 23 8.+
10
H 7 8.+
if 3 V.S.+
II
i 120
12
if 10
13
i 30 S.+
14
1
V " S.+
i
15
Y 60
f 64 8.+
i6
J39S.+
it 13 +
H 7 V.8.+
17
i! 29 +
i! 3 8.+
l8
if I6 + + +
U ao + + +
if 16 +
19
a i6s 8.+
ii 979 8.+
i IS4 8.+
n 31 V.8.+
Sl 5
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110 A Clinical Study of
TABLE OF EXAMINATIONS OF
Acute Poliomyelitis.
SPINAL FLUIDS (ODNTINUED).
II
xst week.
adweck.
3d WMk.
4th week.
Stb week.
6tb-zoth week.
20
*36 +
1§ IS4 8.+
H 12 8.+
ff 20 +
ii 5
21
H6 +
JJ6 +
Ha 8.+
M II 8.+
22
} 174
{ 44
Y "9 8- +
23
H" +
f»I2 +
24
} 6
} 62 8.+
i 59 8.+
Â¥so
25
f la V.8.+
H 8 v.e.+
iJ 10 V.8.+
«40
H40
26
4 i6 8.+
f 10 V.8.+
H 10
27
H » ++
«6 +
Ha 8.+
H 3 V.8.+
28
Â¥ 6 + +
Â¥ II 8.+
H4
a 10
tt4
29
} 10 8.+
i 14 + +
a 3 ++
l?a + +
Us ++
Its +
11 3 V.8.+
30
t 55 V.8.+
t 295 8.+
31
i650 +
32
4 6z
f 147 V.8.+
Â¥7 +
« I 8.+
33
t i6o +
34
i 58 8.+
U »3 8.+
H X8 8.+
35
} 297 +
it 38 + +
H 27 + +
!}8 +
iJ 13 8.+
36
^ 26 8.+
H" +
n 7 8.+
t« 4 V.8.+
37
4 69 8.+
HP 8.+
H 8 V.8.+ 1 fi 3
38
+! 12 8.+
â– i II 8.+
«I4
39
H 8 V.8.+
Hs +
H 4 V.S.+ it 2 V.8.+
40
4 13 S.+
t|l8 +
a 7 +
*} 24 8.+
}| 3 8.+
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Francis W. Pedbody, Oeorge Draper, and A. B. Dochez. Ill
TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS (OONTINUED).
wi week.
ad week.
3d week.
4th week.
5th week.
6th-xoth week.
41
â– f 22
42
Â¥40
27
T P +
Â¥ 3 ..1+
43
} 12 V.8.+
H3 +
}f II 8.+
B iss +
ils+*
tt 10
44
i 39 8.+
«29 +
\i 53 V.S.+
H120
45
} 33 V.8.+
a I 8.+
}«3
46
i 37
f 44 V.8.+
10 57
H II V.8.+
H 12 V.S.+
47
J IS +
V 12 +
«25 +
18 2 V.8.+
48
* 55
f IS +
»^ 22 +
1*2 +
ils +
It 2 8.+
Sf 4 8.+
}| 3 V.8.+
49
f 8 V.8.+
a 4 V.8.+
a 40
1
SO
i 42 8.+
V 6 +
H30 +
a 7 +
lun
SI
I 83 8.+
V 23 V.8.+
!J II 8.+
52
i 58 8.+
f 5 8.+
H6 8.+
iJ3 +
1* 4 8.+
il I V.8.+
S3
i 113
1 239 V.8.+
1 112 V.8.+
« 5 8.+
fj 36 V.8.+
MX2 +
If 4 V.8.+
54
i 133
»i8 +
H 4 8.+
1 J«3
55
t 20 V.8.+
i 55 V.8.+
Hio +
i
56
\i 35 V.8.+
iJ9 +
a 8 8.+
H 6 V.8.+
57
} 196
H 8 8.+
f» 5 8.+
1
1
58
i 94
59
f 12 V.8.+
V-8 8.+
li 8 8.+
6o
} 18
J 90 V.8.+
« 3 8.+
fl30
1
6i
J 203
i«i8 +
«6 +
62
If 2 ..+
63
f 473 8- +
1 1
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112
A Clinical Study of Acute Poliomyelitis.
TABLE OF EXAMINATIONS OF CEREBROSPINAL FLUIDS (CONTINUED).
xst week.
3d week.
3d week.
4th week.
5th week.
6th-zoth week
^4
i 6i
J 320 V.S.+
f 6o
n 25
a II V.8.+
•65
i S2 8. + H 14 8.+
li 7 V.S.+
•66
} 22 V.8. +
t 114 V.8.+
1
•67
M40
•68
f 26
Â¥5 +
H 5 V.S. +
H59
A 90 1 V 14 i f J 5
1
mately the same, the usual extremes being 10.8 per cent., reported by
Zappert from the epidemic in Northern Austria of 1908, and 22.5
per cent, reported by Lindner and Mally*® from the epidemic in
East Austria in the same year. The mortality, furthermore, varies
somewhat with the age of the patients. In younger children the
outlook is better than in older ones and adults. Thus, Wickman
found the death rate per cent, in patients below eleven years of age
to be 1 1.9, and in cases between the ages of twelve and thirty-two,
27.6 per cent. Our series of seventy-one hospital cases showed a
mortality of about 14 per cent. The figure, however, becomes much
lower if the total number of cases applying for admission be used.
In this total the death rate is 6.8 per cent. The hospital cases repre-
sent, in general, the sickest patients that applied.
While such statistics are of great value in giving a general con-
ception of the fatality of the disease, they are of little help in the
presence of a given case of poliomyelitis. This, of course, is true in
some measure of all fatal diseases, but with acute poliomyelitis
there is a peculiar element of chance not present in other general
infections; namely, the accident of the lesion destroying simultane-
ously the phrenic and intercostal centers, an accident which is in-
variably fatal. Unfortunately, there is no way of knowing where
the lesion will occur, or if an existing lesion will advance. Flaccid
legs, arms, or facial muscles point only to the cord segment most
seriously injured when the case is first observed, and form no cri-
*• Lindner and Mally, Deutsch, Ztschr. f. Nervenh,, 1910, xxxviii, 343.
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Francis W. Pedbody, George Draper, and A. B. Dochez. 113
terion of the extent or subsequent behavior of the lesion. Anterior
horn cells that lie immediately outside the zone involved by the
pathological process may continue to functionate properly, so that
the proximity of the lesion to the phrenic and intercostal centers
does not necessarily make the outlook worse. This and the fact
that in most cases the initial lesion in the cord is the final one, and
rarely advances, is perhaps the most encouraging knowledge that we
command in attempting to make a prognosis as to life; for, as was
pointed out in the section on paralysis, death in uncomplicated polio-
myelitis invariably results from failure of the muscles of respira-
tion. In other infectious diseases where death has been considered
to depend upon toxemia, mortality statistics represent more nearly
an average failure of human resistance, affected less, perhaps, by
the element of chance. Consequently, at the bedside of a patient
acutely ill with poliomyelitis, where the outward signs of the
state of the disease are, from the nature of the malady, so unsatis-
factory, the physician experiences an unpleasant sense of obscured
vision. There are certain clinical features, however, which may
help us in some measure to form an idea upon which to base
prognosis as to life. Death, according to Wickman, occurs most
often on the fourth day of the paralysis, the third to the seventh
being the limit. In our cases, death occurred once on the second,
four times on the third, once on the fourth, and once on the
fifth day of the paralysis. Figuring, however, not in days of
paralysis, but rather from the onset of the disease, the fifth day
has been the most fatal, with limits from the fourth to the eighth
days of the disease. We therefore made it a rule not to declare
children out of danger until after the eighth day from the first
appearance of muscular weakness.
Usually, the fatal cases are very ill in the first two or three days,
and in our series all had paralysis of one or both deltoids; that is,
an involvement of the cervical cord. The extreme prostration and
the upper extremity paralysis, unless the case was of the rapidly
ascending type (Landry), have been the only tangible prognostic
features. An impression, however, derived largely from the pa-
tient's psychic state, has helped materially. In practically all the
fatal cases the peculiarly alert cerebration, described under the sec-
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114 A Clinical Study of Acute Poliomyelitis.
tion on the fatal cases, has been present. None of the profoundly
stuporous or highly irritable cases have died. Consequently, we
have been glad to see patients in the early days either irritable
or drowsy. One case, in particular, recovered, whose rapidly as-
cending paralysis, first involving both legs, then one arm, then the
back and neck, had led us to give a bad prognosis. This patient was
very drowsy, and was irritable if disturbed.
Paralysis of either diaphragm or thoracic musculature alone is
not necessarily of bad prognostic significance. Children with such
involvement, however, are rather prone to develop bronchopnetn
monia, which is then almost always fatal. Nevertheless, we saw
one instance in a boy of twenty-one months, who reached the hos-
pital with a paralyzed diaphragm and a resolving consolidation of
lobar pneumonia. He made a good recovery.
Another equally difficult question in the prognosis in poliomye-
litis is that which arises during the preparalytic stage ; namely, will
paralysis occur, or not? As in the rapidly advancing cases, where
it is impossible to know whether or not the respiratory muscles
are about to fail, so here the same sense of obscured vision baffles
the physician. We have found absolutely no certain way of antici-
pating paralysis. Occasionally the patient may complain of pain
in a member which is subsequently lamed. This is unsatisfactory,
however, because pain in general is such a common feature of the
disease. Furthermore, the disappearance or absence of a knee
jerk is no infallible signal of approaching weakness. One abortive
case which we observed practically from the day of onset through-
out the course, was the source of hourly apprehension for eight days.
At one time, on the third day of the disease, the knee jerks, which
had been exaggerated, became much less easy to obtain. Three
days later the left knee jerk reacted on reenforcement only, but no
paralysis developed. In a similar way it is impossible to determine
whether or not an advancing paralysis is about to stop. As a rule,
although figures on this point are inaccurate and unconvincing, our
experience has been that the initial paralysis is final. Nevertheless,
there are enough examples of late involvements to make the antici-
pation of further paralyses quite justified at any time until the
seventh or eighth day.
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Francis W. Peabody, Oeorge Draper, and A. R. Dochez. 115
A discussion of the prognosis in poliomyelitis necessarily involves
a consideration of the ultimate disability caused by the disease. It
was formerly supposed that the paralysis was always permanent.
Wickman's extensive studies, however, and the report of the Massa-
chusetts State Board of Inquiry show that this fortunately is far
from the truth. For example, of the 530 cases, one to one and a
half years after the acute attack, which were analyzed by Wickman,
56 per cent, were paralyzed, and 44 per cent, were cured. The
records from Massachusetts indicate a considerably lower percentage
of complete recoveries, — 16.7 per cent. Complete return of power
is more apt to occur in children than in adults. It is still too early to
be able to report figures of value from our hospital cases. We have,
however, been much struck by the surprising return of power which
may occur after a few weeks in limbs that seemed hopelessly para-
lyzed, and we have been even more impressed with the marked im-
provements occurring after several months of a stationary condi-
tion of the paralyses.
TREATMENT.
At the present time there is no specific form of therapy by which
the paralyses in acute poliomyelitis may be prevented, or by means
of which resolution of the inflammatory process and, consequently,
return of function may be hastened. The problem of treatment,
therefore, consists in preventing the spread of the disease to other
persons, in applying general s)miptomatic procedures, and in attempt-
ing the restoration of muscular efficiency and the prevention of
deformities.
Inasmuch as the direct contagiousness of poliomyelitis and its
dissemination by healthy intermediaries are now definitely estab-
lished facts, the maintenance of strict quarantine is essential for the
public health. In this disease, which in its sporadic form has been
with us so long, and towards which there is apparently a high indi-
vidual immunity, it is peculiarly difficult to convince many persons,
both lay and medical, that a quarantine is not somewhat superfluous.
Recent investigations, however, which show that in some epidemics
the number of families or houses with more than one case may reach
40 per cent.; that "persons have been attacked by poliomyelitis
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116 A Clinical Study of Acute Poliomyelitis.
several days after a short and single contact with a patient " ;^ that
markets, fairs, schools, and public gatherings may be the means of
spreading the disease ; that transmission by f omites probably occurs ;
that the virus may exist in the saliva and nasal mucous membrane
in monkeys and in the tonsils in man ; and that it may also be found
in the dust from the rooms of patients, have convinced public health
authorities that poliomyelitis should be treated like any other defi-
nitely contagious disease. In Sweden, Norway, Germany, many
provinces of Austria, and in a number of states in this country,
poliomyelitis is one of the diseases in which notification, quarantine,
and disinfection are required by law. We have already mentioned
the outbreak in Nebraska in 1909, which was apparently checked by
imposing an absolute quarantine for three months on all members
of a patient's family with the exception of the bread winner. The
Paris Academy of Medicine recommends the passage of a law which
would "allow the interdiction of school attendance for three months,
and would apply equally to patients and convalescents." It is prob-
able, however, that the general enforcement of such prolonged quar-
antine would work hardships which would scarcely be compensated
for by the results obtained. The question as to how long the disease
ought to be considered contagious is a most difficult one. That the
disease is contagious during the prodromal stage and perhaps also
during the incubation period is, unfortunately, extremely probable.
Some authorities believe that isolation should be continued through
the acute stage of the disease, until the subsidence of pain, hyper-
esthesia, and all acute symptoms. In our own work we have drawn
a rather arbitrary line based on the fact that in the experimental
disease in monkeys, the virus rarely persists after three or four
weeks. That it may persist longer in monkeys, and probably also
in human beings, is of course certain, but we have felt that this gave
the best practical rule for hospital purposes. We have endeavored,
therefore, to isolate the children in the hospital until about four
weeks after the onset of the disease. We have then allowed them to
go home, but have urged that, when possible, they be kept apart
from other small children for several weeks more.
"Notification of Poliomyelitis — ^Translation of a Report Presented to the
Paris Academy of Medicine on " Obligatory Notification of Poliomyelitis