â ^The tongue is slightly coated with a whitish fur. Pharynx is reddened, tonsils
somewhat large. Head. â Anterior fontanelle bulges a very little (diminished
after lumbar puncture). Neck. â Patient cannot hold her head up. The posterior
muscles are not stiff to flexion. Superficial lymph nodes. â ^The posterior cervical
and occipital nodes are palpable.- Thorax. â ^Well formed. It does not move
properly in respiration. The whole thoracic cavity is drawn down with each
inspiration. There is apparently complete intercostal paralysis. Lungs. â Clear.
Heart. â ^Apparently normal. Abdomen. â Full, not distended. The urinary
bladder reaches nearly to the umbilicus. Patient does not void. Abdominal
respiration is marked. Liver and spleen are not felt. Extremities. â October 13.
There is complete flaccid paralysis of both lower extremities this afternoon.
Knee jerks and Achilles reflexes are absent on both sides. There is no Kemig's
sign present and Kemig manipulation does not cause pain. There is apparently
flaccid paralysis also of the right deltoid and upper arm. The left has tone.
October 14. The left arm also seems to be flaccid this morning. Surface. â A
few fine petechiae are scattered over the surface.
Spinal fluid : 30 c.c. of very slightly opalescent fluid, pressure not increased ;
cells, 423 ; globulin, slightly + 1 sugar, +â¢
Blood count: leukocytes, 25,300; differential count of 200 cells: pol3rmorpho-
nuclears, 59 per cent; transitionals, 13.5 per cent.; lymphocytes, 23.5 per cent;
basophiles, 0.5 per cent.; large mononuclears, 2.5 per cent.; eosinophiles, o;
stimulation form, i per cent
The child is drooling at the mouth. Her face and lips arc cj'anotic The
respirations are short and shallow and the lungs clear. There is practically no
movement of the ribs on the left side, although there may be slight retraction
Francis W. Peabody, Oeorge Draper, and A. R. Dochez. 161
on inspiration; on the right side the ribs move slightly. Abdomen moves with
respiration but the diaphragm seems weak. At intervals there is a deep forced
inspiration. The accessory muscles of respiration are called into play.
Respiration is irregular this afternoon, and at times is of a Cheyne-Stokes
character, two or three deep forcible inspirations and then a pause in which one
hears a few very shallow and weak respirations; then again two or three deep
breaths. The strong expirations are associated with a forcible jerky upward
movement of the diaphragm. Pressure on the abdomen and blocking of the
action of the diaphragm causes great distress and difficulty with respiration.
The child is very limp; there is apparently paralysis of the legs, intercostals,
arms, and neck. She is very pale and slightly cyanotic The accessory muscles
of respiration (stemomastoids) are used, and occasionally the child throws her
head back and her lower jaw forward with inspiration.
October 15. The child gradually grew weaker during the night and, without
change in symptoms, died at 6:30 a. m.
Helen K., age, 3 years and 10 months. Bergenfield, N. J. Admitted, August
19, 191 1. Died, August 21, 191 1. Diagnosis. â ^Acute poliomyelitis.
Family History, â N^^ative. Habitat: the family lives alone in a house in
the country. The next house is twenty-five feet away. The house is new and
clean. They have one pet dog which is healthy. No parasites. No possible con-
tact of child or parents with anyone lame. The family has lived in the country
for five years.
Past History, â The child was normal at bicth, had chidcen pox as a baby and
measles last year. No scarlet fever or diphtheria. She has always had a weak
stomach and vomits occasionally.
Present ///ne^j.â Last Wednesday, August 16, three days ago, the child went
to Rockaway. The day before she was perfectly well. She ate very little
breakfast that morning before starting for the seashore, vomited while on the
cars, but on arrival ate a big dinner. In the afternoon she went wading in the
surf and had a chocolate soda. Then she began to feel sick and complained of
a headache. She ate no supper. At 8 p. m. she vomited, and vomited three times
that night She was restless at night and very feverish. No especial tender-
ness, but rather irritable. The next morning she vomited again. The doctor
thought she had "wind on the stomach." At thift time she walked but was
" weak on Iter legs." There was no change all day. Yesterday she was about
the same. Her legs were weak, she could walk, but did not want to stand. She
sat up last evening and fed herself at supper. The mother says her arms
and legs ** quivered "yesterday. At three o'clock this morning the mother put
her on the water closet and she ** collapsed." The mother then noticed that she
could not move her arms, ^e has had a fair appetite, has vdmited frequently,
and the bowels have been coristipated. No convulsions, no especial sweating. She
has been very dull tod sleepy for several days. Her mother thinks she passed no
urine yesterday. She complained of headache at first and pain in the back,
but not in the arms and legs. Two dayis ago. her voice became very weak. It
is more normal now.
Physical Examination.'âTht patient is a well built, apparently strong child.
162 A Clinical Study of Acute Poliomyelitis.
Sensorium is clear, but she is distinctly dull and sleepy. The cheeks are some-
what flushed, lips and conjunctiva of good color. The face is symmetrical.
Eyes, â Pupils are equal, regular and react normally. Ocular movements are
normal. No strabismus. Ears, â No discharge or tenderness. Nose. â No dis-
charge or excoriation. Mouth, â ^The tongue protrudes straight and has a thick
gray coat Lips arc dry, no herpes. The teeth are in fair condition. Both tonsils
are large but not reddened, and there is no exudate. Neck, â The neck resists
flexion and attempt to flex is painful. CAw/.â Well formed and symmetrical.
Costal angle just under ninety degrees. Respiration is almost wholly abdominal ;
chest moves very slightly with respiration. When the hand is put over the
abdomen and pressure made to obstruct the diaphragm, there is no increase in
thoracic respiration, and she complains that she cannot breathe and respiration
gets more rapid. There is no marked rosary or Harrison's groove. Lungs. â
Inspiration is short, clear throughout on auscultation and percussion. Heart. â
No enlargement Left border inside nipple line. Action is regular and rapid.
Sounds are of good quality. A soft systolic murmur is heard over the pre-
cordium. Abdomen. â Level, soft, symmetrical, tympanitic, no masses or tender-
ness. Abdominal reflexes not obtained. No tache cer6brale. Liver, â Flatness
extends from the sixth rib to the costal margin, edge not felt. Spleen. â Not felt
Muscular system. â Legs : movements of both legs are possible, no paralysis can
be made out There is possibly some weakness, but the child is so sick that it
is hard to be certain of this. The Achilles reflex is present on both sides. The
other reflexes are negative. The left quadriceps acts well The attempt to elicit
Kernig's sign causes pain and muscular spasm which prevents complete exten-
sion. Arms : the shoulder muscles are completely paralyzed. The child can flex
and extend the forearms at the elbows but does so very weakly. Flexion and
extension of the Angers and extension of the hands dorsally are possible, but
all movements are weak. The child can sit up, but the neck muscles are weak
and the head has a tendency to drop backwards or sideways. The back muscles
seem strong. She sits up well. Sensation: there is pain in the back of the
neck on flexion and on attempting Kemig's sign. No especial hjrperesthesia
noted. The voice is somewhat rasping and harsh, but strong.
August 19. Blood count: leukocytes, 10,000; differential count of 200 cells:
polymorphonuclears, 61 per cent ; larg^e mononuclears, 6.5 per cent ; transitionals,
5 per cent.; lymphocytes, 26.5 per cent.; eosinophiles, as per cent; stimulation
form, 0.5 per cent Spinal fluid: 20 cc. of absolutely clear, colorless, watery
fluid; pressure, 180 mm.; cell count, 120 per c.mm.; sugar, 4-; globulin, very
slight turbidity, normal; smear, practically all the cells are mononuclears and
nearly all are lymphocytes.
August 20, The temperature is still elevated. The weakness of the hands
seems more marked. Legs : there is definite weakness of the quadriceps on both
sides. Knee jerks are both absent Other movements are pretty strong. The
Achilles reflex is not obtained on the right, and is slight on the left The
respiration is 42 to the minute; it is wholly abdominal and is very jerky. On
pressure over the abdomen and upwards towards the diaphragm, respiration
becomes more rapid and labored, and her face becomes quite flushed. No move-
ment of the chest surely referable to intercostals was discovered. The child
complains of pain in the back, but of no other tenderness.
Francis W. Peabody, Oeorge Draper, and A. B. Dochez. 163
August 21. Urine examination: yellow, turbid; reaction add; Fehling's test
for sugar negative ; test for albumin with heat and acetic acid negative, with potas-
sium ferroc3ranide negative. No change in the child's condition yesterday. She
was restless during the night but respiration remained the same until it suddenly
changed at 7 o'clock this morning and the doctor was sent for. The child is lying
on her back. The sensorium seems perfectly clear. The skin has a pale grayish
color. The lips are dark red, rather cyanotic. The child is in a profuse sweat.
The pupils are equal, regular, and react normally. Ocular movements are normal.
The tongue protrudes straight. The temperature is normal. The child has
difficulty in swallowing but takes some milk. She raises frothy mucus which she
does not spit out, but holds between her lips and waits for it to be wiped off.
Her respiration is short, jerky, and wholly abdominal. The upper ^art of the
chest moves with respiration but is pulled down on inspiration. The abdominal
respiration is normal. With inspiration the ake nasi dilate, and there is a pro-
trusion of the lower jaw. The stemomastoids and muscles of the neck stand out
Lungs: the right front is clear, respiration normal; left front, the respiration is
very feeble ; both backs are full of coarse moist rales. The heart is regular and
normal. The abdomen is negative. The legs are as before, perhaps weaker. The
arms are as before, movements of the hands weaker. The general condition is
quite characteristic She is perfectly clear mentally and speaks clearly but rather
abruptly, telling exactly what she wants, " My arm hurts," " Turn me over,"
" Scratch my nostril." Apart from this, she desires to be let absolutely alone.
" Don't touch my chest," " Leave me alone, doctor," she says. Her bowels have
moved twice; after each movement the child is somewhat more cyanotic.
10 A. u. The child is very cyanotic, her respiration is irregular and jerky.
She is moribund. The pulse is regular at 64; then it suddenly becomes more
rapid, perhaps 100 (still regular) for a series of beats, then gradually drops down
to about 64 again. Respiration becomes more feeble and suddenly ceases. The
heart continues to beat forcibly and regularly for some minutes. Then it
becomes more feeble and somewhat irregular, though in general the arrhythmia
is of the type with a series of beats at regular rhythm, changing to a series of
regular beats at another rate. The heart beats become more infrequent, and the
heart stops beating five and a half minutes after respiration stopped.
Alfred K., age, 15 months. New York City. Admitted, October 14, 191 1.
Died, October 17, 191 1. Diagnosis.âAcutt poliomyelitis.
Family HÂ«/ory.â Negative. Habitat: the family lives in bad surroundings.
The house is an old wooden structure with a bakery in ftont and living rooms
in the rear. The bedrooms are dark. There are flies, mosquitoes, and all
varieties of vermin. There have been no acute infections in the house lately.
There have been no cases of poliomyelitis in the immediate neighborhood, but
there was one case two blocks away " some time ago."
Past History, â The patient has always been a healthy child with the exception
of some slight gastro-intestinal trouble.
Present Illness, â The onset was rather sudden on Monday night, October 9, five
days ago. The child was restless, could not sleep, cried a great deal, and seemed
to have pain in the head. There was no spontaneous vomiting, but the child was
164 A CUnical Study of Acute Poliomyelitis.
given ipecac and then vomited a little frothy mucus. On the next day he had a
fever. Three days ago he had a slight convulsion, and on the following night
had short general convulsions involving the whole body with the exception of
the lower extremities. He has had muscular twitchings and a coarse tremor of
the hands. There has been no nasal discharge. Sphincters have not been
affected. Two days ago paralysis of both legs was noticed and at that time all
reflexes were absent. Yesterday there was beginning weakness of the right arm.
There has been no respiratory involvement. Temperature, pulse, and respiration
have been as follows : October lo, temperature 102.6* F., pulse 140, respiration 6a
October 11, temperature 102.6" F., respiration 48. October 12, temperature
loi* F., pulse 130, respiration 36. October 13, temperature 100.2* F., pulse laa
October 14, tenq>erature 98.6* F. Child has been very constipated, urination
has been normal.
Physical Examination, â ^The child is a well developed, strong baby, lying
quietly on his back. The eyes are open and the child is not asleep, but he seems
languid and takes no interest in anything. The head is square and the cranium
bulging. Anterior fontanelle is not closed. The face is symmetrical Eyes. â
Pupils are equal, regular, and react normally. Ocular movements are normaL
Eyelids close normally. Ears, â No discharge or tenderness. Nose. â ^No dis-
charge or excoriation. Mouth.^^Tht tongue has a thic)c gray coat There is a
distinct groove in the median line. The lips are dry. Bodi tonsils are enlarged
and boggy; no exudate and no especial redness. Superficial lymph nodes. â There
are small glands in the neck, axillae, and groins. Neck. â The child resists flexion,
it evidently causes pain. ChesLâWtW formed, costal angle ninety degrees, moves
normally with respiration, no rosary or Harrison's groove. Lungs. â Qear
throughout Heart. â Normal in size, sounds clear. Abdomen.^-Full, very soft,
tjrmpanitic, no masses or tenderness. Abdominal reflexes are barely obtained.
There is no tache c^r^brale. The abdominal muscles lack tone and seem very
weak. There is no contraction when the child sits up. Liver. â Flatness extends
from the sixth rib to the costal margin. Edge is just felt Spleen. â Not fdt.
Muscular system. â Movements of the arms seem strong. Legs: both knee jerks,
both Achilles reflexes, and both Kernig's signs are absent. There is no resistance
to the Kemig manipulation on the right, and on the left only slight tightening
of the external hamstring as the leg is extended (muscles all paralyzed), but
extension is quite painful. There is no tenderness on pressure over the legs.
Back: when the child is made to sit up the body falls forward over the legs,
bending at the hips. There is paralysis of the gluteals, erector spinas, and neck
muscles. The head cannot be held up but drops loosely forward, backward, or
to one side. Cremasteric reflexes are active. Surface. â ^The skin is rather dry
but not hot There is no rash. The lips are slightly pale.
October 17. Spinal fluid : 6 c.c. of clear, colorless, watery fluid, pressure low ;
cell count, 114 per cmm.; mononuclears much increased; globulin, very slightly
+ ; sugar, +.
The child does not look so well. He appears weaker and his respiration is
rapid. The temperature has not risen. The child has some difficulty in swallow-
ing, but can still take food. The tongue is apparently straight, but he will not
stick it out. The chest moves well with respiration. The accessory muscles take
some part in respiration. The abdomen moves paradoxically. There is distinct
Francis W. Peabody, Oeorge Draper, and A. B. Dochez. 165
retraction on inspiration, paralysis or weakness of the diaphragm associated with
the weakness of the abdominal muscles noted before. On auscultation both
sides of the chest are full of coarse moist rales, the fronts more so than the
backs; there is no consolidation. The legs are paralyzed. The arms and face
are unaffected. The child does not cry at all loudly (laryngeal involvement?).
II :30 A. M. The child has changed remarkably in the last hour. He is quite
cyanotic and the respiration is short and labored. Breathing has become worse
and the heart irregular (Luciani periods) until respiration practically stopped*
Artificial respiration was then begun and camphorated ether injected. In a few
minutes the heart was regular and rapid, and respiration fairly regular and
deeper than before. His color was much better, and child could breathe alcme.
The intercostal muscles appear to be weakening now. With each respiration the
lower ribs flare, but there is little or no movement of the upper ribs. The
diaphragm is not descending. There is increasing activity of the accessory
muscles of respiration in the neck. They are acting strongly, and with each
inspiration there is a depression and protrusion of the lower jaw. The irreg-
ularity of the heart seems to bear some relation to cyanosis, increasing as the
color gets worse. The child is unconscious. The skin has been gray and
cyanotic since this attack began. It is quite edematous and marks of the stetho-
scope over the chest and also over the shins persist for a long time. During the
period of apnea which occurred suddenly and in which the child appeared to be
djring, the heart action assumed a curious irregularity, but one which was similar
to that which we have seen in several other cases of respiratory failure. The
heart would beat regularly at a rate of about 84 for a period of 10 seconds and
then at a rate of 36 for 6 or 7 beats. This alternation of rapid and slow series
of beats occurred over a considerable period of time, probably a minute and a
half or two minutes. During the latter part of this time, artificial respiration was
being carried on, and the heart action then became regular and rather rapid.
When the patient began again to breathe spontaneously, the heart rate
became rather slower and continued to be regular. After about 10 or 15
minutes the child again had respiratory failure. This time, however, the heart
did not show the rhythmical changes in rate, but gradually became slower and
weaker with slight sinus arrhythmia from time to time. The heart continued to
beat, giving the normal sounds, at a fairly regular rhythm for three minutes after
the breathing finally stopped, at least nothing could be heard after three minutes,
except possibly the vaguest sound in the region of the second right interspace.
Electrocardiographic records, however, show that an action current was formed
for 24 minutes after breathing stopped and 21 minutes after the sounds had
Jesse L., age, 5H years. New York City. Admitted, July 20, 191 1. Died,
July 20, 191 1. Diagnosis, â ^Acute poliomyelitis.
Family if u/ory.â Negative. Habitat: the family lives in a fifteen family
house and knows of no sickness in the same house. The child and the parents
do not remember ever having come in contact with anyone who is lame or
paralyzed. The child has been in New York since last summer when he went for
a few days to the country. There are no animals in the house. The building is
old, but fairly clean and airy.
166 A CUnical Study of Acute Poliofnyelitis.
Past History,â 'The child has always been perfectly well.
Present Illness.^On Wednesday, July 12, eight days ago, the mother noticed
that the child was feverish. She gave him citrate of magnesia, and the next morn-
ing he appeared to be well On the following three days, Thursday, Friday, and
Saturday, the child was up and played normally. Saturday night, however, five
days ago, the child complained of pain in the back and was very restless and
tired. He slept poorly and the next morning complained of severe pain in the
head and back. He was given castor oil and vomited. Dr. Taylor saw the child
in the evening. At this time he had pain and a stiff neck and his temperature
was loaÂ® F. Note by Dr. F. L. Taylor, who has had the case under his care
since July 16: "The child has been ill for three days â ^apparently some digestive
disturbance and coryza. Was given castor oil by mother. Last night complained
of intense frontal and occipital headache; pain in the back of the neck and
upper dorsal spine with retraction of head. Tendon reflexes were perhaps slightly
exaggerated. There was twitching of the individual muscles of the extremities
as the patient lay in bed. Temperature 102.2Â® F. (rectal) ; pulse isa Has
Kemig's sign and no Babinski reflex. Respiration 50 to 60 and shallow. Heart,
lungs, and abdomen negative. Leukocyte count, 7,000; polynuclears, 81 per cent
Monday morning, July 17, condition unchanged. Lumbar puncture: 15 cc. of
crystal clear cerebrospinal fluid obtained under some pressure (i. e. came out in
a spurt). Differential count shows polynuclears, 71 per cent.; lymphocytes, 21 +
per cent ; endothelial cells, 2 + per cent ; incubation negative. Tuesday : reflexes
obtained ; tendency to somnolence ; takes nourishment well. Temperature, pulse,
and respiration about the same. Wednesday afternoon : respiration 36, tempera-
ture loiÂ® F., pulse 120, quite somnolent, very weak. Urine: specific gravity 1,009,
slightly acid, clear, heavy deposit of phosphates, no albumin, no sugar. Cell
count: leukocytes, 3,000; polynuclears, 58 per cent.; small lymphocytes, 28
per cent; mononuclears, 14 per cent During the night the child had great
difiiculty in breathing, partial paralysis of the muscles of respiration, left arm,
and left leg." The mother says that she first noticed weakness of the legs on
July 18, two days ago. There has been no vomiting other than at the onset
except yesterday when the child vomited once; no undue sweating. The mind
has been clear.
Physical Examination. â The patient is a well built little boy, lying on his
back. He is perfectly conscious and aware of all that goes on around him, but
talks with difiiculty in a very weak voice. Respiration is very labored and rapid,
the abe nasi dilating with inspiration, and with each inspiration there is a
marked contraction of the stemomastoids on both sides. Associated with this
is an extension of the neck and a protrusion of the jaw. The chest itself does
not move at all with respiration. The abdomen moves in a normal manner, but
the excursion of the abdominal wall is limited and weak. The skin is clear and
white. Mucous membranes are pale. There is no discharge from the nose. The
lips are covered with dry crusts. Eyes. â Movements of the eyd)alls and pupillary
reactions are normal. Ears. â Hearing is apparently normal. There is no dis-
charge and no tenderness over the mastoids. Mouth. â The tongue is coated and
protrudes straight. The teeth are in good condition. The tonsils are enlarged
and ragged; there is no exudate. No herpes. Superficial lymph nodes. â There
are small glands in the neck, axillae, and groins. Chest. â ^Well formed, costal
Francis W. Pedbody, Oeorge Draper, and A. B. Dochez. 167
angle about ninety degrees. The chest does not move with respiration. Heart.â
NormaL There is a systolic murmur all over the precordium, most marked at
the pulmonary area. Lungs, â ^Both fronts are normal on auscultation and per-
cussion, but the breath sounds are very feeble. As far as can be ascertained,
the backs are also normal, but turning the child over disturbs him greatly.
Abdomen.âLcvel^ soft, tympanitic, no masses or tenderness. Abdominal wall
moves normally with respiration, but to a limited extent The abdomen is
symmetrical. Liver. â ^Flatness extends from the sixth rib to the costal margin.
The edge is not felt Spleen. â Not felt Muscular system. â Legs: the Achilles
reflex is present on the right side, the other reflexes are negative. Movements
of the legs: it is difficult to ascertain how far the legs are paralyzed and how far