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.
Treatment.
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.
