POLIOMYELITIS ANTERIOR ACUTA INFANTILIS. ITS ETIOLOGY AND TREATMENT. A CLINICAL STUDY OF SEVENTY-FIVE CASES.1 BY ANNA M. GALBRAITH, M.D., Attending Physician and Instructor in Diagnosis and Clinical Medicine, Woman's College, PROGNOSIS. As regards Life.-Erb' says "acute atrophic spinal paralysis does not appear ever directly to threaten life; its prognosis is therefore absolutely favorable so far as life is concerned." Seeligmüller' says "the possibility of a fatal termination in the initial stage cannot be known, although no case has been published in which the anatomical condition of a child dying of convulsions was the same as that of a child with infantile spinal paralysis. It is certainly most desirable that the spinal cord of children dying with severe convulsions should always be carefully examined." Strümpell goes a step further when he says "it is not impossible, but it is not yet proven, that many of the cases where children die speedily with convulsions are to be regarded as the initial stage of acute poliomyelitis." Gowers says "the danger to life is probably greatest when there is severe constitutional disturbance, and is, in consequence of this, often before the development of the characteristic paralytic symptoms." Drummond' reports an autopsy made in the case of a girl, 5 years old, who died six or seven hours after the commencement of her illness. Eddy' reported a case in which he had given a favorable prognosis, based, as I understood it, simply on the grounds of the diagnosis. The child died on ' Continued from p. 831, December number. * Ziemssen's "Cyclopedia of the Practice of Medicine," vol. xiii., p. 706. "Spinale Lähmungen im Kindesalter." "On the Nature of the Spinal Lesion in Poliomyelitis Anterior Acuta," Brain, 1885-1886. 5 Transactions of the Illinois Medical Society, 1892, discussion of a paper on Infantile Paralysis. the fourth or fifth day, soon after the development of the paralysis. Seeligmüller's hypothesis of the possible fatal termination of this disease has now been proven by autopsies to be a truism. The accompanying statistics would indicate that the attending physician frequently fails to properly diagnosticate the disease, even after the paralysis develops: DIAGNOSIS AND PROGNOSIS BY ATTENDING PHYSICIAN IN TWENTY-SEVEN 2-13 Poliomyelitis anterior, seen at hospital during acute stage.. I. Patient under doctor's care, but disease not recognized; "inability to walk was due to weakness, and the child would outgrow it". II. Patient under doctor's care, but the mother, and in one case the patient, was the first to recognize the paralysis..... 2 III. Patient under doctor's care, but the paralysis was not noticed till child began to go about... 10 IV. Onset was so insidious that the dragging of the foot was the first thing recognized.... Minus last four and two cases diagnosticated at hospital....... 33 6 27 i.e., in 27 cases the disease was properly diagnosticated in 2 cases only, or 7.4 per cent. From the above facts-viz., (1) that the disease cannot be positively diagnosticated before the appearance of the paralysis; (2) that even then many physicians do not recognize the paralysis as such; (3) that in a case of death under similar circumstances no autopsy is made, and therefore the cause of death cannot be known-it is highly probable that poliomyelitis anterior is much more commonly fatal than statistics would warrant us in believing. Among my own cases are the following notes: 1 brother died with spinal trouble at 2 months; 1 brother died at 18 months while teething in June; 1 brother died of convulsions; 3 brothers died of summer complaint, no convulsions. In severe cases, at least, the prognosis as regards life would be well to be guarded. 1 2. The Prognosis as to the Relation of the Mode of Onset to the Initial and Permanent Paralysis.-Erb-and Seeligmüller says practically the same thing-says of the initial fever: "It has been very little examined and investigated as yet. It is not yet determined whether the fever stands in any definite relation to the intensity and extent of the disease in the initial stage, but it certainly appears as though the intensity of the fever bore no definite relations to the extent of the disturbances that are left behind." Gowers says: "The relation of the general disturbance to the onset of the paralysis presents great variations, which appear (from comparison of cases) to be independent of any variations in, or special features of, the spinal symptoms." "There is no proportion between the intensity of the fever and the extent of the subsequent paralysis" (Jacobi). Since there have been so few records of the temperature made during the acute stage, I will give the rather imperfect ones of four cases, three of which I saw during the attack, and the fourth one month later, in which the temperature chart was kindly sent me by the attending physician. CASE I.-Patient æt. 13 months, first seen on seventh day of attack: CASE III.-Patient æt. 1 year. Furnished by attending physician : In his typical temperature chart Gowers gives as the highest temperature reached the second and third days 101°; the normal temperature-98°-on the seventh day. Cases 1 and 2 would accord with this. In both these cases the onset was gradual and the initial paralysis was limited to one lower extremity. Of the 69 cases in which the mode of onset was ascertained, there was pyrexia without coma or convulsions in about 45 per cent; this ranged from "feverish" to a temperature of 101° to 103.2°, with a duration of from 12 hours to 3 weeks; average time, 5 to 6 days. The onset was said to be apyretic in 6 per cent. This view is wholly theoretical, since the thermometer was not used, and occurred in cases coming on during the night or suddenly while the child was playing. The fever may be accompanied by convulsions-in 14 per cent of the cases varying from a single convulsion, lasting 10 minutes, to a series of convulsions lasting 8 hours; or there may be a comatose condition present-8 per cent lasting from 12 hours to 4 days. TABLE SHOWING THE MODE OF ONSET IN SIXTY-NINE CASES OF POLIOMYELITIS ANTERIOR, WITH THE INITIAL PARALYSIS AND EXTENT OF PARALYSIS AT THE TIME OF EXAMINATION. I. Pyrexia: The fever was either high, continued, or accompanied by coma or convulsions. Trunk and both lower extremities.. 1 Both lower extremities..... 1 2 1 .... 2 46 Right lower extremity. 3 1 1 Total.... 4 4 'Three of the above cases were paralysis of both bladder and rectum, and 1 of the bladder alone. 'In 1 case paralysis of both bladder and rectum. |