AUTHOR'S INDEX NO. PAGE Alley, Reuben G., Some historical facts leading up to our modern health ideals.. ALLISON, CATHERINE B. and HUBBARD, ROGER S., A study of the determination of uric acid.... Subacute combined degeneration of pernicious anemia... and HUBBARD, ROGER S., The effect of high protein diet on some blood constituents. -and HUBBARD, ROGER S., The blood picture in achlorhydria... -Note on the determination of uric acid in the cerebro spinal fluid.. -The effect of a meal upon the titratable alkali of the blood.. WARD, J. FRANCIS, The history of epilepsy.. WARREN, CHARLES W., Impaired carbohydrate tolerance in chronic arthritis.. -A report from the diabetic department of the Clifton Springs Sanitarium and Clinic for Ascending acute anterior poliomyelitis, report of case with autopsy. W. S. THOMAS AND E. A. BAUM- GARTNER... The diagnosis of early diabetes. F. R. WRIGHT. Periodic health examination. ROGER S. MORRIS, M.D., Cincinnati, Ohio. The study of the chronic gastro-intestinal case. C. HARVEY JEWETT, M.D., F.A.C.P. Major General William Crawford Gorgas. H. G. KNOLLS. Subacute combined degeneration or pernicious anemia. S. F. SERVICE AND E. A. BAUMGARTNER. ASCENDING ACUTE ANTERIOR POLIOMYELITIS: W. S. THOMAS AND E. A. BAUMGARTNER Reports of cases of ascending paralysis Case 21075 B. a male aged 22 years en- tered Nov. 14, 1926 with a complaint of paralysis of both lower extremities. Three days previously he started out on his day's work as a truck driver but about mid fore- noon returned home on account of pain low in the back and sides and a headache. The previous days he had had a slight cold. Be- sides the pain the next day he was some- what dizzy and his legs felt weak. That night while walking about the house his left leg suddenly became paralyzed. The next day he could walk a little when supported then paralyzed and that the patient had a slight fever. The third day he was quite comfortable and the following day entered this hospital. He then had much frontal headache, was somewhat nauseated, and His temperature on entry was 100+, pulse 120 and respiration 25 per minute. His blood pressure was 80 over 55 but the next morning was 135 over 75. Examination showed a well developed young adult male with completely paralyzed lower extremi- ties. A neurological examination revealed normal sensory findings throughout. The knee jerks were absent as were the achilles reflexes. There was no ankle or patellar clonus and the Babinski toe test was nega- tive. No cremasteric or abdominal reflexes were obtained. The grips of both hands ap- peared only fair for a well muscled young adult. The legs showed a complete flaccid paralysis. There was no pain on passive motion. The examination otherwise was negative. In the laboratory tests the blood PATHOLOGY DEPARTMENT. The and otherwise a normal differential. blood Wasserman was negative and the urine showed a few leucocytes only. Course: On the first day in the hospital the patient had to be catheterized and an enema had to be given. The second day a spinal puncture showed a clear fluid under rather markedly increased pressure with 135 cells, mostly lymphocytes, positive globulin, a negative Wasserman and the sugar 0.073 per cent. Early in the morning the head had been slightly retracted but this was greatly relieved following the puncture. At this time the right upper extremity was completely paralyzed and the left arm weaker while the right chest appeared paralyzed with over action of the cervical muscles. The other neurological findings were as before but the patient could void and the bowels moved voluntarily. Respirations were 30 to 40 per minute several times on this day and the patient was quite apprehensive. The temperature reached 103 and the pulse 121. The third morning the patient was laboring for breath and slightly cyanotic. Several times during the day he appeared in bad condition but each time improved. During the night he was quite cyanotic at times. He was given morphine and early the fourth morning strychnine. His temperature dropped to 99, the pulse was 100 and the respirations at times labored and rapid. He died during the early morning. The body was that of a well developed and well nourished young white man. Examination of the surface revealed nothing worthy of note. No abnormalities were found in the thoracic and periteneal cavities with the exception of a few tiny petichiae on the epicardium at the junction of the auricles and ventricles and a slightly enlarged spleen with rather large and poorly outlined splenic nodules but no increase in splenic pulp. Gross examination of the central nervous system showed few changes. There was some injection of the blood vessels in the pia arachnoid in both brain and spinal cord. The crebro-spinal fluid was clear and was not appreciably increased in amount. In the mid portion of the thoracic cord there was a segment about five centimeters long which was definitely softened. The degree of softening was such that when the cord was laid on the table this segment was distinctly flattened. Upon sectioning after fixation in formaldehyde however this softened area showed no apparent difference from the other parts of the cord, the grey and white matter were easily differentiated and there was no gross hemorrhages. Upon microscopic examination of sections stained with hemetoxylin and eosin the grey matter of the cord from the medulla to the cauda equina was infiltrated with lymphoid cells in large numbers and not a few polymorphonuclear leucocytes. This cellular infiltration was almost as well marked in the posterior horns as in the anterior (fig. 1 to 4). The large cells in the anterior horns were greatly reduced in number and those which remained showed various stages of degeneration, while the majority have lost their nuclei a few showed these well stained and apparently in a perfect state of preservation although the bodies of the cells showed evidence of degeneration. All of the blood vessels in the grey matter (fig. 1) showed lymphoid cell infiltration in their walls and the tissues immediately surrounding them. There were a few polymorphonuclear leucocytes but these were in the minority. There were occasionally small hemorrhages. The only change from the normal noted. in the white matter was the perivascular infiltration with lymphoid cells (figs. 3 and 4). This was quite marked and involved all of the vessels large and small. The autopsy findings definitely make the case one of anterior poliomyelitis. The question in the early stage of the disease however was not so easily settled. A transverse myelitis due to continued jarring by riding a truck over more or less rough roads was thought possible but discarded because of lack of any sensory changes. At the time also it was thought possibly to be one of polyneuritis but here again the lack of sensory involvement, pain and tenderness made one rule this out. Landry's paralysis with a more or less rapidly developing ascending paralysis was thought quite probable, especially because of the quite long interval (3 days) between the onset of paralysis and the definite progress to involvement of the arms which appears quite slow for acute poliomeylitis. Such cases are, however, not unknown. FIG. 4.-Section from white matter showing perivascular infiltration. The case after the legs were paralyzed was one of the myelitic type of poliomyelitis which when the chest and arms become involved changed to the ascending Landry's type and aroused the question of a true Landry's disease. The rather slow progression of paralysis was against acute poliomyelitis as the latter is more likely to cause its complete paralytic damage in a short time after the onset of paralysis. In Landry's disease there is seldom any fever and rarely such headaches as was complained of two days after and before the first paralysis occurred. The case showed then that acute poliomyelitis does develop its paralysis over several days time. The temporary blocking of the bladder and bowels is occasionally observed in poliomyelitis. The rather marked rise in temperature in the third day after the onset of the first paralysis is not usual. The gross pathological findings were unusual in that the appearance of a reddened well marked gray matter was not observed. The definite perivascular infiltration in the cord is well brought out in the figures but anterior horn cell destruction is not as well seen in the areas here shown as in some others found. A case of ascending anterior poliomyelitis with the paralysis developing over several days time is unusual enough to be interest ing and simulates Landry's paralysis enough to make the diagnosis difficult. The definite history of severe headaches, thể temporary blockage of bladder and bowels, the fever, and the definite spinal fluid findings however make the diagnosis of poliomyelitis even before autopsy. THE DIAGNOSIS OF EARLY DIABETES* Authorities claim that diabetes mellitus is on the increase. Joslin (1) estimates that there are a million diabetics in the United States and is of the opinion that a campaign for its prevention holds the same promise as preventive measures against tuberculosis and other preventable diseases. Probably it is true that the diagnosis of early diabetes in most cases is more simple than the diagnosis of incipient tuberculosis. However, more than a routine examination of the urine is needed in this search for the early diabetic, and many so-called prediabetics will escape detection if the routine analysis of the urine is supplemented only by the fasting bloodsugar determination, for there are borderline cases which show a transient glycosuria and do not always have a fasting hyperglycemia. In such cases the test for glucose in the urine may be positive on the first examination, but on the second test, a few days later, glucose is absent. Now, if the fasting blood-sugar varies and is only occasionally above the normal, the real significance of the transient glycosuria may be lost. In such cases the tolerance of the patient to carbohydrate must be studied before a diagnosis can be made. Glycosuria *Read at the meeting of the Seventh District Branch, at Geneva, New York, September 29, 1926. Reprinted from the New York State Jour. Med., 27; 122, 1927. alone cannot be regarded as pathognomonic of diabetes. Glycosuria is a symptom and its cause must be ascertained in each case. All reducing substances are not glucose, although glucose is by far the most common substance in the urine which reduces the copper reagents. In the ordinary diet carbohydrate forms. more than sixty per cent of the food ingested and yet it probably constitutes not more than one per cent of the body weight. Thus it is seen that sugars and starches are the most easily metabolized of the foodstuffs. So, if the process of metabolism is disturbed, one would expect the disturbance to be manifested particularly in the carbohydrate. The disturbance in metabolism is characteristic of diabetes mellitus and is shown most obviously in respect of that kind of food which is eaten abundantly and which forms the smallest part of the body structure. The limit to the amount of sugar which the normal individual can assimilate is sufficiently high for all ordinary needs. One has to take one-quarter per cent of his bodyweight (approximately 175 grams for a man five feet, eight inches in height) of glucose at one time before any will appear in the urine under normal conditions. And no amount of starch should cause sugar in the |