154

DIAGNOSIS AND TREATMENT OFACUTE ANTERIOR POLIOMYELITIS

J. M. K. SPALDING, D.M., M.R.C.P.Department of Neurology, Radcliffe Infirmary, Oxford

The diagnosis and treatment of acute anteriorpoliomyelitis is a matter of concern to everyclinician, for the earliest indications of the diseasemay be non-specific, and dangerous symptomsmay develop rapidly. When this occurs treat-ment is life-saving, but incorrect treatment onlyadds to the patient's dangers.DiagnosisMinor Illness. In about 40 per cent. of para-

lytic cases the ' minor illness ' is the first symptomof poliomyelitis. It is characterized by malaise,fever, sore throat, headache and catarrh, andusually lasts about 48 hours. It is absent inmore than half the paralytic cases, and whenpresent it is so non-specific that it can only bediagnosed in retrospect. The suggestion has beenmade that this stage represents a period ofviraemia, but the evidence is conflicting.Major Illness. The major illness develops

three to ten days after the minor illness, and in theinterval the patient usually considers himselfperfectly fit, although occasionally the minorillness merges indeterminately into the majorillness. In 90 per cent. of cases the major illnessdevelops abruptly. It begins with the meningiticphase, characterized by fever, malaise, headache,vomiting and pain in the neck, spine and limbs.Catarrh is rare at this stage, and meningiticsymptoms prominent, the neck being stiff andflexion painful. Nystagmus may occur. Thecerebrospinal fluid (C.S.F.) though very rarelynormal, almost always contains excess cells,varying from about 20 to 500 per c.mm. Themajority of the cells are usually polymorphs, andoccasionally as much as 80 per cent. polymorphsare found. The polymorphs are replaced withina few days by lymphocytes, which themselvesdisappear soon after the fever subsides. Theprotein at first is raised only slightly, and consider-ably less than in pyogenic meningitis with asimilar cellular reaction, but as the cells disappearthe protein rises to Ioo or 200 mg. per Ioo ml., orhigher, and may remain elevated for several

weeks. The glucose content of the C.S.F. isnormal throughout. Neither the severity of themeningitic symptoms, nor the degree of pleo-cytosis in the C.S.F., give a guide to the severity ofparalysis that may follow.The aching in the limbs may be severe or it may

be so mild that the patient may be inclined to'work off his rheumatism' by vigorous exercise,with disastrous results. Though the severity ofthe pain does not enable a forecast to be made aboutthe paralysis to be expected its site gives someindication, for paralysis is more likely to developwhere the pain is felt. Muscular fasciculation,similar to that in motor neurone disease may beobserved, and this is a diagnostic sign and anindication that the muscles showing fasciculationwill shortly become weak.The meningitic phase and the minor illness (if

it occurs) constitute the whole illness in non-paralytic cases.* Such cases can in general onlybe diagnosed on probabilities from the nature ofthe illness and the presence of poliomyelitis in thepopulation. New laboratory procedures, how-ever, are being developed. which make it possibleboth to demonstrate complement-fixing antibodyand to grow the virus on tissue culture fromfaeces or sputum. Poliomyelitis virus has beencultured from 98 per cent. of paralytic cases, butonly from 42 per cent. of cases diagnosed clinicallyas non-paralytic poliomyelitis. It now seemsreasonably certain that a large proportion of thelatter were not infected by poliomyelitis virus atall (Weller, 1954).

The paralytic phase of the disease usually beginsat the time when the fever and symptoms of themeningitic phase are abating (Fig. i). Theremay be a delay of 12 or even 24 hours after thefever subsides before the onset of paralysis, and itis important that the patient continues to rest inbed during this period, even though he feels

*'Non-paralytic' cases must be distinguished from'abortive' cases, in which the virus multiplies in thebody and is excreted in the stools, but in whichsymptoms are either absent or non-specific.

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from

April 1955 SPALDING: Diagnosis and Treatment of Acute Anterior Poliomyelitis 155

STAGES OF DISEASEMAJOR ILLNESS

IIINOR ILLNESS PROOROA

__________iM8 -//NON SPECIFpIC OR

CATARRHAL SYMPTOMS

|-- il||lllli|ll MENINGEAL OR SPINAL SYM-PrOMS.

P FEVER

P PARALYSIS

ia!fllB!111 lllll !1i//ll""""'-'lllIli,! II -~ i !i - lr-

P

uliwUilWWUEMhhENIua11 .uu ,iilb l.

-.Pt 2 3 4 5 6 7 8 9 10 II 12 15

DAYS OF DISEASE

FIG. i.-Diagram to show various patterns which thedisease may take (from Russell, I952).

completely recovered. It is an unfavourable signif low-grade fever continues or fever recurs afterthe onset of paralysis, for further paralysis maythen occur. This is unlikely when the tempera-ture has been normal for 24 hours. It is unusualfor paralysis to spread for more than four or fivedays, and very exceptional for it to do so morethan a week from the onset of paralysis.The paralysis may affect any of the voluntary

musculature of the body, and it is particularlyimportant to recognize immediately the onset ofthe paralysis which may endanger life, that isinvolvement of the muscles of respiration or ofswallowing. If serious weakness of the primarymuscles of respiration develops, the respiratoryrate rises, the patient becomes restless and anxiousand when speaking pauses for breath every fewwords; the alse nasae move with respiration, andthe accessory muscles of respiration, if not them-selves paralysed, are brought into use. If therespiratory centre is affected, a similar picture ispresented with, in addition, irregularities ofrespiratory rate and volume. These signs indi-cate an already serious state of affairs, and ifpossible a more accurate estimate of the progressof events should be obtained by measuring thevital capacity with a spirometer or, more con-veniently, with a dry gas meter.* This should

*e.g. Type C.D. I Meter (Parkinson and CowanIndustrial Products, Ltd., London).

TABLE IVITAL CAPACITIES IN NORMAL SUBJECTS

Weight Vital Capacity(lb.) (litres)35 I.370 1 .8o05 3.0140 4.2.175 4.6

Approximate ventilation required for patients ofdifferent weights. The minute volume should be in-creased 10 per cent. when the patient is awake and 5per cent. for every i F. of fever (adapted from E. P.

Radford).

be done repeatedly for any patient who has severeparalysis of the upper limbs or who is suspected ofrespiratory weakness, and if the vital capacity fallsto one third or one quarter of the normal (Table i),artificial respiration is likely to be required. Ifno spirometer is available, the patient should bemade to take a deep breath and count aloud asfar as possible. The normal person can countconsiderably more than 50, and if 15 is all that canbe achieved in a single breatth, artificial respira-tion will probably be necessary.

Paralysis of swallowing, often loosely referredto by the more general term ' bulbar paralysis,' isas dangerous as weakness of respiratory muscles,but the two conditions must be clearly distin-guished since the treatment is entirely different.The danger lies in the risk of pulmonary damagedue to inhalation of secretions, food, or mostdisastrous of all, vomit. Weakness of swallowingmay be obvious to patient and observers, ormanifest itself as choking over food or medicine.Development of a nasal voice may herald diffi-culty in swallowing. Children, however, mayrefuse to take food if they know they cannotswallow it, and if this is dismissed as anorexia, amost significant observation is missed. A patientwith a pool of secretion in the pharynx may findthat in order to prevent it running into his tracheahe has to breath shallowly and rapidly. If thisincrease in respiratory rate is attributed wronglyto weakness of respiratory muscles, the patientmay be put into a tank respiratory, and this willinevitably lead to the inhalation of the secretionswith disastrous results.

InvestigationsThe principle investigation in a case of suspected

poliomyelitis is lumbar puncture, and the C.S.F.changes have already been described. Contro-versy flares up from time to time whether lumbarpuncture is indicated in poliomyelitis. There is

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from

POSTGRADUATE MEDICAL JOURNAL

no evidence that lumbar puncture is harmful, andthe general principle should be applied that aninvestigation should be done if, and only if, it islikely to provide useful information. In themeningitic phase the diagnosis of poliomyelitis isalways presumptive; and but for the existence ofcontroversy it would seem hardly necessary tostress that lumbar puncture may be essential todistinguish between poliomyelitis and bacterialmeningitis, and that the early diagnosis ofbacterial meningitis is of the first importance.On the other hand, when paralysis has developed,the diagnosis may be so clear that lumbar puncturewould be pointless.Differential DiagnosisThe minor illness is indistinguishable except in

retrospect from other non-specific fevers. Themeningitic phase of the major illness has to bedistinguished from other causes of meningitis.The insidious onset of tuberculous meningitis andthe rapidity with which drowsiness and disorienta-tion follows on frank symptoms of meningitiscontrasts with the abrupt onset of the meningiticphase of poliomyelitis and the remarkable pre-servation of consciousness in that disease. If doubtexists, search should be made for lesions in thechest, tubercles in the retina and acid-fast bacilliin the C.S.F. When polymorphs predominate inthe C.S.F. the distinction from pyogenic menin-gitis is difficult. A source of infection in the chestor middle ear must be sought and the C.S.F.thoroughly examined for bacteria. Diminutionin the glucose content of the C.S.F. is much infavour of pyogenic meningitis. Benign lympho-cytic chorio-meningitis may only be distinguishablewith the aid of complement-fixation tests. Mumpsmeningitis is rarely confusing unless the parotitishas been minimal. Acute toxic polyneuritis isdistinguished clinically by the symmetrical natureof the paralysis and by the presence of sensory losswhich may be predominantly posterior columnin type. It is further distinguished by thehigh protein content of the C.S.F. withoutincrease in the cells, but this distinction is lost oneor two weeks after the onset since in poliomyelitisthe cells disappear and the protein rises at thisstage. Other diseases which have been confusedwith poliomyelitis include neurosyphilis, brainabscess, intracranial and spinal tumour, cerebralhaemorrhage, pneumonia, influenza, rheumatoidarthritis, rheumatic fever, scurvy and hysteria(Blattner, 1954).TreatmentMeningitic Phase

During the meningitic phase it is probable thatthe fate of the lower motor neurones hangs in the

balance, and therefore anything which increasestheir susceptibility to the virus must be avoided.It has been shown (Russell, I949, Horstmann,1950) that exercise during the meningitic phaseincreases the probability of severe paralysis in theexercised limbs, and therefore during an epidemicof poliomyelitis anyone suffering from symptomssuggestive of the meningitic phase should rest inbed until the fever and symptoms have subsidedfor 24 hours. In deciding whether a patientmust rest or not, meningitic symptoms and painsin the back and limbs are especially significant,whereas catarrh in the absence of those symptomsis very rarely an indication of poliomyelitis.Paralytic Phase

Treatment in the paralytic stage has twodistinct objects, first the preservation of life, andsecond the prevention of deformity.

Preservation of Life. Deaths due to polio-myelitis are almost all due to respiratory failureor pulmonary complications, but the mechanismof these disorders varies, and since the treatmentdiffers widely according to the nature of thetrouble, it is essential to distinguish clearlybetween them.

In primary respiratory failure the intercostalmuscles and diaphragm are weak, or the respiratorycentre fails to perform its rhythmical function,and in either case, adequate ventilation is notachieved. Artificial respiration in a tank type ofrespirator is then required. The patient mustnot be left until he is grossly underventilated andcyanosed before he is put into the respirator.When his vital capacity has fallen to one third orone quarter of normal, he should be told that atthis vital time it is necessary to rest his musclesand that therefore a machine will be used tobreath for him. He can then be put into therespirator without hurry, and his co-operationcan be obtained both in making him comfortableand in synchronizing his own respiration with thatof the machine. A confused and anoxic patienton the other hand, may exhaust his remainingstrength struggling against the machine.When a patient first goes into a respirator it is

wise to give him some deep respirations to showhim that good reserves are available and to ensurethat any accumulation of carbon dioxide iseliminated. Prolonged hyperventilation should,however, be avoided, since it introduces circulatorydangers in the acute stage, and subsequentlymakes weaning from the respirator difficult.A negative pressure of I6 cm. water at a rate ofi6 respiration/minute may be satisfactory, butwide variation from this figure occurs. Todetermine the actual ventilation occurring, theexpired air should be measured. To do this a

April I955156copyright.

on March 2, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.31.354.154 on 1 April 1955. D

ownloaded from

April 1955 SPALDING: Diagnosis and Treatment of Acute Anterior Poliomyelitis 157

....'

.'.lll...'..;'. ..

:'...:i..'.........

:i:~:. ·....

i~:, :::::::::::::::::::::::::::::::::

FIG. 2.-Apparatus used for measuring ventilation of a patient in a tank respirator.

face mask is required to which are attached twoshort wide-bore tubes. These tubes are fittedwith low-resistance valves so that inspired airenters through one and expired air leaves throughthe other, and is collected in a spirometer orpassed through a dry meter (Fig. 2). Thesize of each breath (tidal air) and, since the rateof respiration is known, the minute volume ismeasured in this way. The machine should beadjusted to provide the minute volume appro-priate to the weight of the patient (Table 2), anadditional io per cent. being allowed when awakeand 5 per cent. for every i°F. rise in temperature.Minor degrees of hypoventilation are often shownby rise in blood pressure due to carbon dioxideretention. Chronic hyperventilation is verycommon in artificial respiration, but it may beminimized if the ph of the urine is estimated daily,preferably on an early morning specimen. Theurinary ph is variable, but is usually 6.o to 6.4 andfrequent estimations about 7.0 suggest a respira-tory alkalosis. This may be confirmed byestimating the plasma bicarbonate which shouldnot be less than 20 m.Eq.l.When the patient is temporarily removed from

the respirator artificial respiration can be main-tained by inflation through a mask. This can beAnne manually or, more conveniently, with a

TABLE 2

Body MinuteWeight Respirations Volume

(lb.) (minute) (litres)14 40 I .435 28 2.870 22 4.2

105 I6 5.0140 I4 5.9175 14 7.0

respiration pump that provides intermittentpositive pressure. It enables nursing, includingcare of the skin at the neck seal, to be performedwithout hurry.When paralysis of swallowing is present treatment

is urgent, for if the patient vomits his life is indanger. The treatment is postural drainage.The patient is turned into the prone or semi-proneposition and the foot of the bed is raised so thatvomit or secretions run out from his mouth.If a tipping bed is not available the bed-legs at thefoot can be placed on two wooden chairs, or in thecase of a child an inverted ' V' frame, as used fortreating bronchiectasis, may be employed (Fig. 3).

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from

158 POSTGRADUATE MEDICAL JOURNAL April I955

~:J~ , , , . :...:..::::~:~,::: :<:..'B!:::a'..~..:::::r:::::~...'.: :~: :: .:~ ::.·;:::...~.. ::..:: :.....::..::::..:.,......::.::.::.· ~~~~<,,~:,.,:::,,m

~~j'~'~~~~ ~ ~ ~ l:::..============'::.f:::::...~'l"'"i:::jj?:::::::::::::::::::::::

,."_ :,,m . ....' ... ::::::::i:ji::::::::::::::::: :':.:.:.':............~~~·· ....,,,~<,,::·,.:....~~~::< iiii;lii:...~, ..;. . . ....................:?:i:;aiiill ::.::~! :...-,.~.~.: ........si.....~~~~~,'~l:i!:~ "' iil.:::.:...::'::........'"~l:ii. ,i,, .. ,:"ii?ii :i.::.... . .. . .:iiiii:.:i. ::-: .. ..:::·~~~~~~~~·:· '~: ..... . :':ii:.:!i.-: " :::!. ~

... ..

................

-i

i'~ ~ ~ ~ ~ ~ ~ ~ ~~~ ~~~~X1 illl-uen~%s~~iiill,~'~ .:1Ba. ··:.:'

:~i

''

> .::s:·:::... ..

,.^:::.:...

FIG. 3.-Two methods of providing postural drainage for a patient with paralysis of swallowing (from Russell,1952).

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from

April 1955 SPALDING: Diagnosis and Treatment of Acute Anterior Poliomyelitis

...:..:..!.. "t:^

···1'4 E·::·jii6s·siM -:

,~IDEI m

-; -, I

.....*--- W.-

FIG. 4.-Apparatus for prolonged artificial respiration by intermittent positive pressure. A,Radcliffe respiration pump. B, Humidifier. C, Stott expiratory valve. D, Pressure gauge.E, Nosworthy connector. F, Tracheal tube. G, Gas meter.

To confirm that the airway remains clear, thetrachea must be auscultated with a stethoscope, ora laryngeal microphone relaying to a loud-speakermay be kept permanently in position. Occasionallytracheotomy may be required to maintain a clearairway. Paralysis of swallowing almost alwaysrecovers in about ten days, but during that timeconstant supervision by an experienced nurse isessential.When primary respiratory paralysis is combined

with paralysis of swallowing, the outlook has untilrecently been exceptionally bleak, for in a tankrespirator, even if the patient is nursed head downand prone (which is only possible with the mostmodern respirators) the uncompromising inspira-tory effort of the machine causes secretions to beinhaled, and it is impossible to keep the lungshealthy. It is therefore necessary to adopt themethod introduced in 1952 in Denmark (Lassen,1953). A tracheotomy is performed and a shortcuffed tracheal tube is inserted.* The cuffperforms the dual purpose of preventing secretionsor vomit from reaching the lungs and of enabling*A suitable tracheal tube can be made by cutting a

Magill endotracheal tube immediately below the cuffand I.5 cm. above it.

the lungs to be inflated by intermittent positivepressure. Inflation should be carried out mecha-nically by a pump of proven reliability (Russelland Schuster, 1953; Crampton Smith, Spaldingand Russell, I954), but in an emergency it can bedone by squeezing an anaesthetic bag. Since theinspired air does not pass through the upper airpassages, it is essential to use a humidifier(Marshall and Spalding, I953) to warm andmoisten it and prevent secretions from formingcrusts which cannot be aspirated. The apparatusrequired for this form of artificial respiration isshown in Fig. 4.

Artificial respiration provided in this way isrelatively simple and leaves the limbs and trunk freefor nursing care and physiotherapy. Detailedmanagement has been described elsewhere(Crampton Smith, Spalding and Russell, 1954),but it should be stressed that the essential require-ment is adequate care of the chest. For this thebasic necessities are that the patient should beturned two hourly, and receive percussion andvibration to the chest once or more daily. Secre-tions should be completely aspirated from bothsides of the chest through the tracheal tube beforeand after turning, and at other times as required.

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from

160 POSTGRADUATE MEDICAL JOURNAL April 1955

Apparatus intended for this form of artificialrespiration must include facilities for measuringexpired air, and the control of ventilation isgoverned by the principles enumerated above.Though patients with tracheostomes have been

successfully treated in tank respirators (O'Brienet al., 1954; Affeldt, I954), the simplicity ofpositive pressure respiration and the full access tothe patient that it provides, makes it the method ofchoice whenever a tracheostome is present.A tracheostome only adds to the difficulty ofmaking a neck seal if a tank respirator is used.

Prevention of Deformity. To provide the bestfunctional recovery, deformities must be prevented,and in particular, watch must be kept to preventfoot-drop, limitation of movement at the shoulder,flexion contracture at the hip and knee, andkyphosis. The advice of an orthopaedic surgeonmay be valuable in this connection. Splints aregenerally unnecessary and inadvisable, but if usedshould be as light as possible. There is, however,scope for ' live' splints and other appliances inwhich elastic or springs are made to take the placeof a paralysed group of muscles (Affeldt, I954).This prevents deformity and allows the patient tokeep the joint mobile and to exercise the musclesantagonistic to the springs. Passive movementsshould be given from the beginning to maintainthe mobility of the joints. There is no evidencethat after the active stage of the disease is over anyobject is achieved by restricting active movements,and on the contrary a good increase in power hasfollowed early active movement (Russell andFischer-Williams, I954). Active movements maytherefore be begun a week after the fever settlesand be steadily increased. Heat, whether in theform of dry heat or hot packs, may soothe thepatient or help to loosen a stiff joint, and if it doesso it should be used. Hot packs, however, have nocurative properties and should not become such afetish that their application interferes with othertreatment or the patient's rest.

SummaryPoliomyelitis consists of a non-specific ' minor

illness' and of a ' major illness' characterized bya meningitic and a paralytic phase. The featuresand differential diagnosis of these stages aredetailed and the danger of exercise in the meningiticphase is emphasized.

Treatment of acute paralytic poliomyelitis hastwo objects, to save life and to prevent deformity.There are three combinations of paralysis whichmay cause death. Paralysis of the respiratorymuscles should be treated with a tank respirator,paralysis of swallowing by postural drainage, andthe combination of the two by tracheotomy withartificial respiration by intermittent positivepressure through a cuffed tracheal tube. Correcttreatment can be life-saving, but incorrect treat-ment is likely to add to the patient's dangers.To obtain the best functional results, deformity

must be prevented. Management aimed atproducing the best functional result is outlined.

AcknowledgmentsThanks are due to Dr. W. Ritchie Russell and

Messrs. Edward Arnold and Co., for permissionto publish Figs. i and 3.

BIBLIOGRAPHYAFFELDT, J. E. (1954), J. Amer. Med. Ass., I56, I2.BLATTNER, R. J. (1954), J. Amer. Med. Ass., 156, 9.CRAMPTON SMITH, A., SPALDING, J. M. K. and RUSSELL,

W. R. (I954), Lancet, i, 939.HORSTMANN, D. (1950), J. Amer. Med. Ass., I42, 236.LASSEN, H. C. A. (1953), Lancet, i, 37.MARSHALL, J., SPALDING, J. M. K. (1953), Lancet, ii, 0o22.O'BRIEN, W. A., SCOTT, A. E., CROSBY, R. C., and SIMPSON,

W. E. (I954), J. Amer. Med. Ass., I56, 27.RADFORD, E. P., National Foundation for Infantile Paralysis.RUSSELL, W. R. (1949), Brit. med. J., i, 465.RUSSELL, W. R. (1952), ' Poliomyelitis,' London (Edward Arnold).RUSSELL, W. R., FISCHER-WILLIAMS, M. (I954), Lancet i,

330.RUSSELL, W. R., SCHUSTER, E. (1953), Lancet ii, 707.WELLER, T. H. (1954), J. Amer. Med. Ass., 156, i6.

copyright. on M

arch 2, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.31.354.154 on 1 A

pril 1955. Dow

nloaded from