New York.

The ordinary conception of anterior poliomyelitis is that of a disease which begins with vomiting, fever and more or less general nervous irritability, occasionally convulsions and delirium. Within one or two days there is paralysis in one or more of the extremities. The text-book descriptions would make the diagnosis very simple because of the early appearance of paralysis and because of the lack of marked cerebral or nervous symptoms and the absence of pain, tenderness or of rigidity in the extremities.

The recent epidemic in New York and vicinity has furnished an opportunity to observe many cases whose symptoms do not agree with the ordinary conception of the disease and has therefore offered many a difficult problem in diagnosis. On this account it has seemed worth while to the writer to make a study of the early symptoms of 63 cases of the disease; of these 20 were under treatment at the Babies' Hospital, 40 were observed at the Children's Department of the Vanderbilt Clinic and 3 were private patients.

The conditions preceding the onset of the disease were not sufficiently uniform in any number of cases to justify any conclusion. Some of the suggestive histories are as follows:

Of the Babies' Hospital cases :

Henry S., two and a half years old. Was taken for a long drive. Came home very tired. Had fever that night and for six days following. Was paralyzed in both extremities on the morning following the drive.

Arthur D., three and one-half years old. Had been vomiting every day from August 24th until September ist. Was not considered ill although he had fever from 99° to 101° F. On the eighth day he was found to be paralyzed in both lower extremities.

Edmund J., three years old. Was in good health, the first symptom being severe occipital pain. This lasted for five days and was accompanied by slight fever. Then it was noticed that he had a general weakness and was unable to stand although he could move the lower extremities.

Rose J., nineteen months old. Perfectly well, and had no vomiting, but fever and restlessness for one day when paralysis was noted in both upper and lower extremities. The fever continued for two days after the appearance of paralysis. There was in this case some rigidity of the neck, but no pain in the paralyzed limbs, the paralysis being flaccid. (This type of case where the patient was in apparent perfect health and was suddenly taken with fever and paralysis was very common throughout the series.)

Arthur F., two and one-quarter years old. Swallowed a penny on September 18th. Was given an active purgative. That night there was fever and drowsiness and weakness of the extremities was noticed. On successive days the legs were paralyzed, the arms were very weak, and finally on the third day showed distinct paralysis.

John L., one year old. Had a cough and low fever for one week; then one morning paralysis was found in both lower extremities. There had been vomiting at the onset.

Sadie B., two years old. Was in apparently perfect health until she fell from bed. Walked a little for the next two days, but on the third day was unable to walk and it was found that she had paralysis of the left arm and leg.

Charles W., thirteen months old. Was apparently well until he fell from a low chair. When picked up it was found that the whole left upper extremity was paralyzed.

Among the Vanderbilt Clinic histories the following were noteworthy :

Rachel F., thirteen months old. Was apathetic and somnolent for one week; was then in a stupor for forty-eight hours; then she became irritable and had an attack of vomiting with fever. There was rigidity of the neck, and on the day after vomiting it was found that both upper and both lower extremities and the left side of the face were paralyzed. There were pains in the limbs early, along the peripheral nerves, in the muscles and apparently also in the joints. Both legs and arms were said to be swollen. The case terminated in complete functional recovery, except in the left arm, forearms and left side of face.

George C., one and one-half years old. Had a high fever up to 105°F., lasting one week, but without any initial vomiting. There was restlessness and delirium. Four days after onset the arms were paralyzed; next the muscles of the back and finally the legs, all within the first week. The muscles of the abdomen were next affected so that the abdomen was distended. There was no pain or tenderness in the limbs and no rigidity of the neck.

Ralph C., two and one-half years old. Had cough and fever for three days. He kept complaining of pain in the left ieg and a sensation of prickling. The paralysis was flaccid and recovery complete.

Eleanor B., six and one-half years old. Felt pain in back of neck on Saturday. On Sunday she walked with difficulty and had a temperature of 101-102° F. On Monday she could not walk at all because of paralysis in left foot and leg.

David S., three years old. Had fever, pain and rigidity of the back and of the neck. The next day there was paralysis of both legs. For two days he was unable to urinate and there was constipation for three days. There was general painfulness of limbs, including the joints and the muscles.

Nellie S., ten months old. A nursing baby. Had fever, slight vomiting, convulsions and coma. Paralysis appeared two days after onset. For two weeks it was necessary to catheterize the baby. There was paralysis of both upper extremities and of both legs.

Ethel H., six years old. Had been trolley riding and had eaten various kinds of refreshments. That evening she vomited and had high fever. In twenty-four hours there was rigid paralysis of the left thigh, leg and foot. Both legs were painful, the muscles of the left leg being especially so. There was no rigidity of the neck.

Among the 3 private cases 2 are worthy of mention :

Baby T., A little girl ten months old. She had a disordered digestion with fever up to 1o1°F., vomiting and great restlessness. In four days she had gradually sunk into a stupor which lasted for three days. She could be roused, but lay very still. The temperature after onset was not over 102°F. Her pulse and respiration were irregular, the latter suggesting CheyneStokes. The fontanel was not bulging, there was no Kernig's sign, and the extremities were flaccid; reflexes normal. On account of the stupor and the irregularity of pulse and respiration, the question of tuberculous meningitis arose, but because of the lack of rigidity of the neck or bulging of the fontanel it was decided to wait a few days before making lumbar puncture. Paralysis of both legs and of the right arm developed in four days and the baby's mind became clear at about the same time.

S. E. J., nine-year-old boy. On September 22d, after a very good summer at Lake George, the boy returned to New York. Had examination at school the following day and went to school on September 25th. On September 26th, after playing in the park for an hour and a half, he became tired and sat on a large stone watching a fire for about an hour. When he went home he was quite tired but seemingly well. That night he was very restless and complained of pain in stomach, although nothing unusual had been eaten. The next morning, September 27th, he had some headache, pain in both eyes, and slight aching throughout body. The right eye was red and there was some lacrymation. His temperature was found to be 101, and there was a little redness of the throat. He was kept in bed all day and had a good sleep that night. The next day, September 28th, he felt well so that he went to the country for over Sunday, taking a railroad trip of four hours. He returned to town on September 30th and seemed well the next day, so that he went to school (October ist). At noon, when his mother went for him, he complained that he could not walk home because he had such a stomach ache and because his eyes pained him on coming out into the light. He walked half a dozen blocks and then began to cry because of pain in the eyes. He sat down on a bench and his hands and feet became cold, although he did not have real chill. After coming home in the street car he went to bed and did not care for any luncheon. When seen by me at five o'clock he had intense headache, photophobia, pain on movement of the eyes and pain on movement of the limbs. The temperature was 1oroF., later mounting to 102°F. The tendon reflexes were all tested at this time without any changes being noted. There was no nausea nor vomiting during the night, but he complained bitterly of pain, mostly in the head. The next afternoon the symptoms were exaggerated, and there was, in addition, pain in the back and neck and stiffness of the neck. Dr. Holt saw the boy in consultation that evening. Complete examination failed to give definite diagnosis. The next day the pain and rigidity in back of the neck were increased, and he was unable to walk, although there was no paralysis. There was, however, an increase of the pain in the extremities. The next day, October 2d, the temperature rose to 103°F. The painful rigidity of the limbs was marked. Dr. Holt saw the patient, and at this time 15 c.c. of clear fluid were drawn by lumbar puncture. The fluid was negative on examination. On October 5th the urine had to be drawn with a catheter, and this was necessary for three days. The rigidity and pain in the back of the neck lasted for nine days. The child developed partial paralysis of both upper and both lower extremities. Painful cramps in the arms and legs were a marked feature and the pain in the legs persisted for three and one-half weeks. The legs were held drawn up and flexed at the knees for two and one-half weeks. After the third week rapid improvement took place. The child spent the winter in Bermuda and has recently returned to New York able to walk without a crutch or brace. There is still some dragging of the right foot.

The peculiar features of this case were: First, the intermission at the onset, there being three days of apparent perfect health after probably what was the beginning of the disease. Second, the intense headache, photophobia, rigidity of the neck, and the peculiar cramping pains and tenderness of all the extremities. Third, the slow appearance of the paralysis.

The details of the more important early symptoms in the 63 cases are as follows:

Vomiting.—This occurred in 25 cases. In i it lasted for six days. As a rule, it occurred only at the time of onset.

Constipation.—This was present in 14 cases; therefore not at all characteristic.

Diarrhea.—This occurred in 17 cases. It was severe, lasting for a week or more in 4 cases. In regard to this symptom it should be emphasized that the cases occurred during the midsummer, and that most of the patients that suffered from diarrhea were young children or infants. It does not seem significant.

Cough, tonsillitis or sore throat existed in only 6 cases.

Fever was noted as present in 52 of the cases. It was probably present in all. The range of the temperature was from 100°-102° F. in the milder cases and 101°-105° F. in the more

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