[Read before the Annual Meeting of The International Hahnemannian Association, Philadelphia, July, 1926.].
Acute poliomyelitis, also called infantile paralysis, regressive paralysis, or acute atrophic paralysis, is an acute in infectious disease affecting mainly children under five years of age, It is caused by a filterable virus which attacks the central nervous system, the parenchymatous organs and the lymphoid tissues. The most prominent symptom of the disease is a rapidly developing flaccid paralysis which improves after two or three weeks, leaving as a rule a few muscles permanently paralyzed. These last muscles undergo rapid atrophy.
The disease occurs sporadically and in epidemics, and during the last twenty-five years the epidemics have increased in frequency and severity. In 1909 Landsteiner and Popper succeeded in innoculating the disease in monkeys by intra-abdominal injections of a bacterium-free emulsion from a boy who had died from the disease. Other workers confirmed these observations, notable among them Flexner. I shall quote in substance from his writings for paragraph or two.
The virus or microbic agent consists of minute globules, capable of being viewed under the high powers of microscope. It is carried by persons, not insects. Animals, except monkeys, do not seem to be susceptible to the virus, and are therefore only passive carries. This virus is not injured by a 5-10 cent. solution of carbolic acid or freezing. It is more sensitive to heat, and can be destroyed in one-half hour by a temperature of 40-50 degrees C. Hydrogen peroxide in a 2 per cent. solution also kills it, as do also menthol and bichloride of mercury. When enclosed in an albuminous envelope, it will withstand drying for several weeks and therefore saliva or nasal mucus can convey the infection by means of a spray produced by a cough, sneeze or loud conversation.
Careful investigation points almost conclusively to the upper respiratory tract as the site of the ingress and egress of the virus. The lymphatics of the nasal mucosa are in almost direct connection with the sub-arachnoid space; they pass with the filaments of he olfactory nerve through the cribriform plate of the ethmoid bone.
The virus of poliomyelitis has been demonstrated in the nasopharynx of infected monkeys and successful innoculation of monkeys by the virus has been done via the pharyngeal mucosa. Large quantities of the virus can be introduced into the stomach or duodenum without producing spinal paralysis if only peristalsis be preserved. In the nasal secretions the virus is extremely persistent.
It was found in a monkey five months after recovery, but it human beings it does not live so long. However, as long as it persists in one who has had an attack or in a passive carrier, that person is a menace to those around him. Ordinarily the disease is communicable for about six days before the development of an attack and ten days after the onset-that is, the period of incubation is usually from five to seven days. However, extremes of two days, and thirty days have reported.
The most susceptible age is the latter half of the second year, and 90 per cent. of cases are in children under five years, 95 per cent. in those under ten. However, no age is exempt; a case is on record of a child twelve days old, and another of a person forty-six years of age.
As a rule, epidemics occur in summer and early fall; that is, in warm weather, but sporadic cases are seen at any time of year. The disease seems to be independent of surroundings. It appears in the country as well as in city and attacks persons in good circumstances as often as those who are very poor-those in previous sound health as well as the more delicate. Dr.Erastus Case reported three case of poliomyelitis, all in persons of tuberculous inheritance, and he wondered if the disease were always dependent on a tubercular root.
It has been stated by some writers that more than one case did not appear in the same family, but this is not true, since in one of the large epidemics there were over two hundred families which had two cases and a few had three or four. As a rule one attacks gives immunity to the disease by the formation of anti- bodies. A second attack is extremely rate. Relapses sometimes occur in a few weeks form the onset and are usually marked by an extension of the paralysis.
Before the discovery of the virus, and its use in animal experimentation, knowledge of the pathology of poliomyelitis was chiefly limited to the finding of atrophic scars in the anterior horns of the cord. This led to the view that the paralysis was due to an embolic plugging of one or more of the anterior, spinal arteries, resulting in the necrosis of nerve tissue and late formation of interstitial scar tissue. It has now been definitely proved, chiefly by experiments with the virus upon monkeys, that the disease is a general infection, attacking not only the cord, not only the central nervous system as a whole, but the peripheral nerves and the viscera, too.
The changes begin with hyperemia of the pia and of the blood vessels which pass into the cord through the anterior fissure, and with the accumulation of lymphocytes and polymorphonuclear leucocytes about them. This process extends into the substance of the core and everywhere the minute blood vessels are found surrounded by a mantle of such cells, so that the more vascular portions of the cord, that is, the cervical and lumbar enlargements, the anterior horns and the gray matter are especially affected.
This leads to a difference of opinion regarding the direct cause of injury to the nerve cells, some writers holding that it is due to the direct action of the virus, and others maintaining that it is owing to obstruction of circulation by the immense number of cells, resulting in pressure and oedema which cause degeneration of the nerve cells. This degeneration varies much in extent. If the pressure is soon removed, regeneration takes place, but if it remains, the cells become necrosed, are cleared away and later are replaced by a dense neuroglia scar. Analogous lesions are found in the medulla oblongata, where the nuclei of cranial nerves become infected, and also in the higher parts of the brain.
Changes in the cerebro-spinal fluid occur early. In from twenty-four to seventy-two hours it becomes opalescent and coagulable, but soon again becomes clear and non-coagulable. This clearing of the fluid in monkeys comes with or just after the appearance of the paralysis. Experiments have shown that this clear fluid is non-infectious, although it may be in excess and may contain an increased number of lymphocytes.
The lymphoid tissues are nearly always affected and cloudy swelling is found in liver and kidneys. Symptomatology.
There seems to be a distinct difference between the sporadic and the epidemic cases, the sporadic case, as a rule, affecting only certain parts of the spinal cord, whereas in the epidemic form the inflammation is usually more general, involving not only the spinal cord but the brain as well, and the pia over both these structures. Wickman divides the disease into eight different forms, as follows :
1. Spinal poliomyelitis.
2. Cases simulating Landrys paralysis.
3. Bulbar and pontile forms.
4. Cerebral form.
5. Ataxic form.
6. Neuritic form.
7. Meningeal form.
8. Abortive form.
The symptoms of a typical case of the spinal form are as follows : A child in previous good health becomes restless and irritable. It complaints of pain and the limbs are tender to touch. Mild fever develops or at times a high temperature, sometimes with vomiting and less often diarrhoea. Convulsions sometimes occur. Sweating is a very constant symptom, also a very marked prostration with diminished of lost reflexes. Blood examination shows a leukopenia. After two or three days the fever usually passes off, leaving the child quiet, with clear mind, but with a localized or a general flaccid paralysis.
The legs, one or both, are most often affected, the arms less often, but any part o the body may be attached. The sphincters are rarely affected. This stage of paralysis usually lasts from one to three weeks and is followed by a relief of the general paralysis, but a more permanent paralysis of one or more groups of muscles.
These atrophy rapidly and present the reaction of degeneration. The affected limb becomes blue and cold and is liable to contractures owing to the action of the unopposed muscles. The joints may also be deformed. In the leg, the quadriceps and the tibialis anticus are most often affected-in the arm, the deltoid. The anterior and internal muscles of the extremities are more apt of suffer than the posterior and external. There is apt to be arrested development of the bones in the affected limb.
The type simulating Landrys paralysis is very rare. The paralysis is progressive and ascending. The pathological process eventually reaches the medulla and the patient dies.
In the bulbar form the nerve nuclei of the pons and medulla are affected and as a result we have dysphagia, dysarthria, dyspnoea and paralysis of various cranial nerves, especially of face and eyes. These cases are rapidly fatal.
The meningeal form includes cases which have rigidity of the back and neck and Kernigs symptom. The symptoms are milder than in cerebro-spinal meningitis and positive differentiation may be made by lumbar puncture.
There are two forms which may be especially misleading as to diagnosis-the cerebral and the abortive. The first is called also polioencephalitis and produces hemiplegias and diplegias in children. The second, or abortive form, was first recognized by Wickman during the great Swedish epidemic of 1995-06, and Flexner has proved its identity by experiments with the blood serum of patients who had it. The serum of such cases neutralizes the virus of poliomyelitis just as does that of typical cases.
A case of this sort begins suddenly with fever, vomiting and great prostration, often accompanied by muscular pains and stiffness of the neck. This clears up in two or three days and the patient makes a perfect recovery. The recognition of the disease and should be isolated. Also, early diagnosis in any case will help to the choice of treatment and so my prevent paralysis. Diagnosis.
Diagnosis is usually fairly easy during an epidemic, but is very doubtful in a sporadic case, especially in the early stages. Lumbar puncture is a great aid.
If the case is positive, the spinal fluid will show increased pressure, opalescent tint (in prodromal stage) an increase in protein and an excess of white cells, especially lymphocytes. After the paralysis has appeared the fluid becomes clear and the lymphocytes diminish in number, though they are still in excess of normal.
The diagnostic symptoms of poliomyelitis are restlessness, irritability, fever, sweats, headache, backache and very marked prostration, followed in twelve to thirty-six hours by a general flaccid paralysis.
The disease must be differentiated from cerebral palsies, which are hemiplegic in distribution and come on suddenly. The tendon reflexes are increased and the electrical reactions are preserved. There is no extreme wasting of the muscles. There is profound mental depression. In poliomyelitis the mentally is unaffected. The tongue, face and speech are normal. There is very marked wasting of the affected muscles with electrical reaction of degeneration and loss of faradic irritability. The reflexes are abolished early.
Cerebro-spinal meningitis, which may be confused with this disease, will usually show a spastic instead of a flaccid paralysis, marked spinal and nuchal rigidity and much more pain than is found in poliomyelitis. Occasionally a case of infantile paralysis is so mild that its occurrence is not noted by the parents until time for the child to begin to walk. It may then be confused with the pseudo-paraplegia of rachitis, but the latter disease shows beading of the ribs, enlarged and tender joints and hyperaesthesia of the extremities. Movements are painful, but possible; there is no muscular atrophy or altered electrical reaction and the deep and superficial reflexes are normal. Prognosis.
Cases of the bulbar type are nearly always fatal, death coming suddenly. Cerebral and meningitic cases are serious. In the strictly spinal form the prognosis is usually favorable as regards life especially in sporadic cases, but the great majority of those attacked suffer some loss of function. Holt says that more children die on the fourth day than on any succeeding day and the prognosis for life is good after the first week. From twelve to thirty years of age the mortality is given as 27 per cent. as against 12 per cent under twelve years.
Flexure stated that in epidemics there was a death rate of 5-10 per cent. and that 75 per cent. were paralyzed to some extent. In one epidemic in Nebraska, however, only 25 per cent. were paralyzed.
If the faradic irritability is lost very early, that it, within a week of the onset of the disease, there is more danger that the paralysis will be permanent, but the longer the loss is delayed the greater the hope of recovery. A return of faradic impulse indicates a return of voluntary emotion. Indeed, it has been proved that in the process of recovery a muscle will respond to volitional impulse before it will react to faradism, and the earlier this return occurs the greater the probability of complete recovery.
Gowers said that an absence of faradic irritability for ten days indicated a permanent partial paralysis, but Sinkler quotes a case where it was absent for fifteen months, and after sixty days of treatment it returned with voluntary motion. Dr. John Eastman Wilson quotes a case of Dr.Hutchinsons in which restoration of function took place after forty-one years of paralysis.
The Patient and his attendants should be isolated during the acute stage, that is, for three weeks from the onset of symptoms. All discharges should be disinfected. Since diagnosis of the disease is so difficult in the first stage, the physician should be on the alert and give especial attention to any case that with catarrhal symptoms presents a degree of prostration out of proportion to the severity of other symptoms. If necessary, lumbar puncture should be done to make clear the diagnosis. As opalescence of the cerebro-spinal fluid would make the diagnosis sure.
During the early stages of the disease absolute rest in bed is necessary,and the patient should lie either on the side, or, if resting on the back, should be on an inclined plane. Massage or electrical stimulation should not be used until after the acute stage has passed. When the paralysis has developed, measures should be taken to prevent deformities, or unnecessary fatigue and strain of the weakened muscles. The patient should not be allowed to swing a dangling foot or to hear weight on a weakened joint. Sandbags will help to keep the limbs in position in bed and a cradle will remove the weight of bedclothes from the feet.
The affected limbs should be wrapped in some soft woollen material or in cotton batting to keep them warm. After the acute stage has passed, gentle rubbing and massage should be used daily, and twice a day the limbs should be bathed for fifteen minutes in water as warm as can be comfortably borne. A salt bath is helpful and gives the child more chance to float and to use its limbs.
Muscle-training should not be started until all acute symptoms have subsided and the muscles have lost their irritability-perhaps six weeks from the beginning of the attack.
After the acute stages is passed, it is much safer and better for the general practitioner to seek counsel from a good orthopedist, rather than to try to carry the case through alone. He will need special aid in the choice of exercises and in measures to avoid deformities.
Also the homoeopath needs to study his remedies most carefully in order to give all the aid possible in combating the disease. In the beginning, belladonna may very likely be indicated, but extreme prostration suggests gelsemium and clinically that has proved very helpful. Causticum, graphites, and plumbum are to be considered in the later stages, along with many other remedies. There is no doubt that the homoeopathic medicines great things in this disease and that Old School consultants are often at a loss to account for the marvelous nerve regeneration that has taken place.