Aug., 1949]
351
EDITORIAL and back
Indian Medical Gazette
is
AUGUST
ACUTE anterior
poliomyelitis
Like most other crippling organic diseases
does not nervous system this disease in India (Greval, 1946). Its occurrence, however, is not unknown. While subjects crippled by it are comparatively rare, atrophy small groups of muscles in an otherwise wellouilt subject, like an army recruit, is often seen. Cases of the disease have this year been leported from Bombay and Delhi, and wc understand that 12 cases have occurred in Calcutta in llP to date, 24th September, 1949, reported this delayed issue for August 1949, also. At the Present moment there exists in the whole have country a scare of the disease. Iron lungs been received from America (Medical News, 1949). An attempt has been made in the lay press by a well-known medical man to allay the scare (Chand, 1949). An article for further iillayment appears elsewhere in this issue
of the
thrive
^
(viswanathan,
1949).
The New Zealand epidemic.?An admirable account of the disease, as it has occurred in an epidemic form in New Zealand, has become 1949). The followavailable lng items
recently (Caughey, are
selected for
special
attention
develops,
without any
paresis;
and
{Hi)
stage of paralytic poliomyelitis in which paresis
:
It is
present.
(7) The CSF may show changes in the second stage.?Pressure is usually moderately high. Cell count varies enormously, 5 to 2,000, preponderance of polymorphs changing later to one of lymphocytes. The count becomes normal in 2 to 3 weeks. Protein content is normal or only slightly raised but rises as the cell count falls. Glucose and chloride are unchanged. The changes give no indication of the serious development of paralysis. (8) Treatment.?It consists of (i) providing a firm flat mattress and a low pillow, (u) sand bags and a cradle, if necessitated by pains in the legs, (Hi) hot packs for the spasm of the muscles, (iv) passive movements within a day or two of beginning the treatment, (v) re-education of the affected muscle a few days later, (vi) ambulation as soon as possible, and {vii) the use of a respirator, if necessary. The respirator is taken in use as soon as it is indicated. The only danger in this treatment is from aspiration of food, vomit, etc. All food by mouth is stopped and a tracheotomy is performed. The feeding is done by the intravenous route (glucose, saline, protein hydrolysate or plasma?1 bottle daily). Prophylactic penicillin is given. A patient may require these
measures
for
a
week
or two.
Result of treatment.?Of 224 patients, 12 still had residual weakness after 12 months and the rest recovered completely.
(9) died,
32
(1) The epidemic type of the disease. The Nicobar epidemic of 1947.?An account of characterized by (i) influenza-like symptoms, 1 u) high mortality, {Hi) muscular spasm, and it was given in this journal last year (Moses, 1948). The epidemic appears to be of consider\lv) hyperesthesia of the skin. able interest in studying the wave of epidemiolis (2) Change in the age incidence.?There The infection was traced to ogy in the East. an increase in the incidence in the age group the Andaman Islands. Incidentally, the writer 5. over 16 and decrease in the age group 0 to of the account drew attention to four special of the population of the Nicobar (3) Contact cases and multiple cases in one characteristics : Islands of infectivity the house.??These cases show that the virus has increased. (1) Isolation.?The people are living by with India. (4) Severity of the disease in relation to the themselves without any intercourse Once in 3 months a steamer from Madras arrives close to the islands and lands goods and stock for the officials from Madras. Very (5) Portal of entry.?Children are more occasionally a daring trader goes to the immediately after tonsillectomy. Andamans. One such trader was supposed to Operation on nose, throat and teeth are contra- have brought with him the disease.
onset
of the
severe.
epidemic.?Earlier
cases
are more
susceptible
mdicated during an epidemic. (2) Special plan of houses.?They are hollow The (6) Three stages of the disease?They con- spheres resting on raised platforms. stitute ({) stage of invasion (or minor illness) entrance is through the floor (from under the w"ich may be referable to as the cold of the platform). There are no windows. Overcrowdupper respiratory tract or of the gastro-intestinal ing in such dwellings is a genius of the people. tract, and lasts 2 to 3 days, settling down with(3) Adenoids.?Due to overcrowding and out any ill effects (hence the name 'Abortive lack of ventilation adenoids are almost a normal polioPoliomyelitis '); (u) stage of pre-paralytic feature and responsible for a anatomical aches myelitis in which, in addition to the usual facial expression. characteristic limbs the of and stiffness of the muscles
pains,
THE INDIAN MEDICAL GAZETTE
352
(4) Water not used as a drink.?Milk from green coconut is the universal beverage. Water is used for
washing
and
cooking only.
Other recent work of clinical interest.? From a summary of previous studies emerge the following : (1) Cases needing the respirator do not do well on the whole, even after an immediate recovery and discharge from the apparatus. (2) Oxygen should be used in addition to the respirator as indicated by Millikan's oximeter. (3) Rectal or subcutaneous feeding is to be preferred to intravenous feeding in view of the oedema of the lungs which is feared. (4) Bulbar involvement is the dreaded complication : involvement of the nucleus ambiguus is indicated by dysphagia and alteration in the voice while that of the reticular formation of the lower medulla by the alteration in the respiratory rhythm, flushing and fall in blood pressure (Rivers, 1948).
Negative signs.?They have also been stressed recently and consist of : (1) cough other than that of laryngeal involvement, (2) diarrhoea, (3) mental clouding, (4) convulsion, (5) rigor, (6) rash, (7) palpable spleen, (8) stiff limb, as opposed to weak, floppy or flabby limb, and (9) persistence of fever after 12 days (Powel, 1949). All of them have been made dogmatic intentionally, some are more so than others. Recently cases diagnosed as non-paralytic poliomyelitis have been found to be suffering from mumps meningoencephalitis, showing the unreliability of clinical diagnoses (Kilham, Levens and Enders, 1949). The Kenny treatment.?It has been commented upon in the House of Commons (National Health Service, questions to the Minister, 1949). It has been included in the selected items in paragraph 3. Details as to the care of individual muscles may be obtained from a brochure on the Kenny method of treatment from the National Foundation for Infantile Paralysis, U.S.A. (Hyman, 1946).
Chemotherapy.??' A number of polio victims were said to be walking around to-day, thanks to the chemical called phenosulphazole, with trade name Darvisul, instead of being paralysed and crippled for life' (Medicine, 1948). This good news has not been confirmed. muscles
(Mackenzie, issue,
in this
electric
reaction of the of recovery 1949; abstract in Current Topics p. 372).
Prognosis.?The
affected
is
indicative
The virus, etc.?From studies on the virus in recent years has emerged a composite group, the
Lansing type (from Lansing, Michigan, U.S.A.). including YSK and MEF. Immunologically, they are interrelated. The natural antibody titre of the human serum, against the type, increases with age. UltraIt consists of 4 strains
[Aug.,
1949
violet-inactivated Lansing virus and formalin-
Lansing virus are capable of mice and cotton rats. Active virus can immunize monkeys. Application of these processes to human beings has not so far been made (Rivers, loc. cit.). Probably they will Conprovide the only sure prophylaxis. valescent sera and anti-viral sera prepared in the horse are useless (Parish, 1948).
inactivated
immunizing
Points in epidemiology.?Lately communication between India and the Andamans has increased. Displaced persons, refugees and business men have gone to prospect. Many have returned. Most of them went from West Bengal and returned to or through West Bengal. The bearing of this movement on the reported incidence of poliomyelitis in India is not yet known. In England the disease is again approaching the incidence of 1947 which was rather heavy. From this increased and widespread incidence, including geographical tracts previously entirely free, it appears that a pandemic of poliomyelitis is in the making.
Prophylaxis, etc.?One single measure which be usefully directed against the disease is prevention of overcrowding such as occurs in cinemas, swimming pools, community bathing in holy waters and congregational worship under one roof. Fatigue and chills must also be avoided. But unfortunately it must be added that prophylactic measures have failed singularly in checking the disease (Editorial, 19496). On the other hand it has been feared that a high standard of living and superior sanitation make the community concerned more liable (Horstmann, 1948). The fear caused by this observation has been allayed recently (Hill and Martin, 1949). A very significant observation against infection by droplets has been made : the disease in England shows a high incidence in autumn when other infections caused by droplets show a low incidence (Editorial, 1949a). Exclusion of flies, water and milk does not
can
appear to make any difference whatsoever. To add to the thorns of a thorny problem of poliomyelitis the hedgehog has crept in unexpectedly. Two animals were found in unusual places in England. One of them was paralysed. The other which was not paralysed has left behind dried spoor which is awaiting investigation (Wilson, 1949; Spicer, 1949). Moles have been suspected for some time as natural reservoirs of the disease. They, cotton rats and Swiss mice have been infected experimentally (Rector, 1949; abstract on p. 370). Emboldened by the defeat of the epidemiologist a non-medical observer in England has suspected peaches for the following reasons.: (1) During the War when peaches were not available there was little evidence of infantile paralysis. (2) After the War when peaches were placed on the market the incidence of the
Aug., 1949]
POLIO
:
VISWANATHAN
and rose. (3) Peach skin is furry porous, unlike that of an apple, which is hard and smooth and can be cleaned better. (4) In Canada, incidence is said to increase every year when peaches are ripe (Maddison, 1949). The peaches, fresh and tinned, may be avoided as well. Peach jam may be safe.
disease
the virus in India. improvement occurs in the Paralysis up to a year has been considered to he an evidence of the chronic nature of the mfection. If the polio scare is found to be correct (by an increased incidence of the disease) and the damage negligible (as is usual, so far), the correctness of the adverse tellural influence on the virus in India will have been proved. That will suggest the utility of tellural hospitals in India for the treatment of cases of polio contracted in Europe and America (Greval, loc. cit.).
Adverse
tellural
?The fact that
influence
on
REFERENCES Brit. Med. Jour., 20th Aug., ii, 406. Calcutta, Statesman, The Chand, A. (1949) 5th Sept., p. 1, col. 6. The Medical Press, 31st Aug., Editorial (1949a) 222, 89. Brit. Med. Jour., 6th Aug., Idem (1949b) ii, 323. Greval, S. D. S. (1946). Indian Med. Gaz., 81, 254. Hill, A. B., and Martin, Brit. Med. Jour., 13th Aug., W. J. (1949). ii, 357. Horstmann, D. M. The Lancet, i, 273.
Caughey,
J. E. (1949)
..
..
..
..
(1948).
Hyman,
H. T (1946)
Kilham, and
Integrated Practice of Medicine. W. B. Saunders Philadelphia Company,
An
..
and London. 16th 934.
L., Levens, J., JA.M.A., J.
Enders, (1949).
Mackenzie,
F.
July,
Proceedings of the Royal Society of Medicine, July,
I. J. (1949).
42, 488.
Maddison,
Jean
(1949). Medical News (1949)
Medicine
(1948)
140,
E. Picture
Sept.,
..
..
Moses, S. H. (1948) National Health Service ..
Post,
London,
3rd
p. 48.
359. Indian Med. Gaz., 84, Science Newsletter, July 31, p 67 Indian Med. Gaz., 83, 355.
The Pharmaceutical Joumal, July, 85. (Questions to the ! Minister) (1949).
Parish,
H. J
Po-wel,
M. L. (1949)
Rector,
L. E. (1949)
Rivers,
T. M. (1948)
(1948)
..
Bacterial and Viral Diseases. E. and S. Livingstone,
Edinburgh. ..
..
..
The Med. Jour, of Australia, 6th Aug., 218. Abstract, Indian Med. Gaz., 84, 370. Viral and Rickettsial InfecJ. B. Man. of tions
Lippincott Company, Philadelphia, London and Montreal.
Spicer,
A. H. (1949) R. (1949). E. (1949)
Viswanathan, Wilson,
..
..
260. The Lancet, 6th Aug., ii, Indian Med. Gaz-, 84, 353. The Lancet, 6th Aug., ii, 260.
353
351
EDITORIAL and back
Indian Medical Gazette
is
AUGUST
ACUTE anterior
poliomyelitis
Like most other crippling organic diseases
does not nervous system this disease in India (Greval, 1946). Its occurrence, however, is not unknown. While subjects crippled by it are comparatively rare, atrophy small groups of muscles in an otherwise wellouilt subject, like an army recruit, is often seen. Cases of the disease have this year been leported from Bombay and Delhi, and wc understand that 12 cases have occurred in Calcutta in llP to date, 24th September, 1949, reported this delayed issue for August 1949, also. At the Present moment there exists in the whole have country a scare of the disease. Iron lungs been received from America (Medical News, 1949). An attempt has been made in the lay press by a well-known medical man to allay the scare (Chand, 1949). An article for further iillayment appears elsewhere in this issue
of the
thrive
^
(viswanathan,
1949).
The New Zealand epidemic.?An admirable account of the disease, as it has occurred in an epidemic form in New Zealand, has become 1949). The followavailable lng items
recently (Caughey, are
selected for
special
attention
develops,
without any
paresis;
and
{Hi)
stage of paralytic poliomyelitis in which paresis
:
It is
present.
(7) The CSF may show changes in the second stage.?Pressure is usually moderately high. Cell count varies enormously, 5 to 2,000, preponderance of polymorphs changing later to one of lymphocytes. The count becomes normal in 2 to 3 weeks. Protein content is normal or only slightly raised but rises as the cell count falls. Glucose and chloride are unchanged. The changes give no indication of the serious development of paralysis. (8) Treatment.?It consists of (i) providing a firm flat mattress and a low pillow, (u) sand bags and a cradle, if necessitated by pains in the legs, (Hi) hot packs for the spasm of the muscles, (iv) passive movements within a day or two of beginning the treatment, (v) re-education of the affected muscle a few days later, (vi) ambulation as soon as possible, and {vii) the use of a respirator, if necessary. The respirator is taken in use as soon as it is indicated. The only danger in this treatment is from aspiration of food, vomit, etc. All food by mouth is stopped and a tracheotomy is performed. The feeding is done by the intravenous route (glucose, saline, protein hydrolysate or plasma?1 bottle daily). Prophylactic penicillin is given. A patient may require these
measures
for
a
week
or two.
Result of treatment.?Of 224 patients, 12 still had residual weakness after 12 months and the rest recovered completely.
(9) died,
32
(1) The epidemic type of the disease. The Nicobar epidemic of 1947.?An account of characterized by (i) influenza-like symptoms, 1 u) high mortality, {Hi) muscular spasm, and it was given in this journal last year (Moses, 1948). The epidemic appears to be of consider\lv) hyperesthesia of the skin. able interest in studying the wave of epidemiolis (2) Change in the age incidence.?There The infection was traced to ogy in the East. an increase in the incidence in the age group the Andaman Islands. Incidentally, the writer 5. over 16 and decrease in the age group 0 to of the account drew attention to four special of the population of the Nicobar (3) Contact cases and multiple cases in one characteristics : Islands of infectivity the house.??These cases show that the virus has increased. (1) Isolation.?The people are living by with India. (4) Severity of the disease in relation to the themselves without any intercourse Once in 3 months a steamer from Madras arrives close to the islands and lands goods and stock for the officials from Madras. Very (5) Portal of entry.?Children are more occasionally a daring trader goes to the immediately after tonsillectomy. Andamans. One such trader was supposed to Operation on nose, throat and teeth are contra- have brought with him the disease.
onset
of the
severe.
epidemic.?Earlier
cases
are more
susceptible
mdicated during an epidemic. (2) Special plan of houses.?They are hollow The (6) Three stages of the disease?They con- spheres resting on raised platforms. stitute ({) stage of invasion (or minor illness) entrance is through the floor (from under the w"ich may be referable to as the cold of the platform). There are no windows. Overcrowdupper respiratory tract or of the gastro-intestinal ing in such dwellings is a genius of the people. tract, and lasts 2 to 3 days, settling down with(3) Adenoids.?Due to overcrowding and out any ill effects (hence the name 'Abortive lack of ventilation adenoids are almost a normal polioPoliomyelitis '); (u) stage of pre-paralytic feature and responsible for a anatomical aches myelitis in which, in addition to the usual facial expression. characteristic limbs the of and stiffness of the muscles
pains,
THE INDIAN MEDICAL GAZETTE
352
(4) Water not used as a drink.?Milk from green coconut is the universal beverage. Water is used for
washing
and
cooking only.
Other recent work of clinical interest.? From a summary of previous studies emerge the following : (1) Cases needing the respirator do not do well on the whole, even after an immediate recovery and discharge from the apparatus. (2) Oxygen should be used in addition to the respirator as indicated by Millikan's oximeter. (3) Rectal or subcutaneous feeding is to be preferred to intravenous feeding in view of the oedema of the lungs which is feared. (4) Bulbar involvement is the dreaded complication : involvement of the nucleus ambiguus is indicated by dysphagia and alteration in the voice while that of the reticular formation of the lower medulla by the alteration in the respiratory rhythm, flushing and fall in blood pressure (Rivers, 1948).
Negative signs.?They have also been stressed recently and consist of : (1) cough other than that of laryngeal involvement, (2) diarrhoea, (3) mental clouding, (4) convulsion, (5) rigor, (6) rash, (7) palpable spleen, (8) stiff limb, as opposed to weak, floppy or flabby limb, and (9) persistence of fever after 12 days (Powel, 1949). All of them have been made dogmatic intentionally, some are more so than others. Recently cases diagnosed as non-paralytic poliomyelitis have been found to be suffering from mumps meningoencephalitis, showing the unreliability of clinical diagnoses (Kilham, Levens and Enders, 1949). The Kenny treatment.?It has been commented upon in the House of Commons (National Health Service, questions to the Minister, 1949). It has been included in the selected items in paragraph 3. Details as to the care of individual muscles may be obtained from a brochure on the Kenny method of treatment from the National Foundation for Infantile Paralysis, U.S.A. (Hyman, 1946).
Chemotherapy.??' A number of polio victims were said to be walking around to-day, thanks to the chemical called phenosulphazole, with trade name Darvisul, instead of being paralysed and crippled for life' (Medicine, 1948). This good news has not been confirmed. muscles
(Mackenzie, issue,
in this
electric
reaction of the of recovery 1949; abstract in Current Topics p. 372).
Prognosis.?The
affected
is
indicative
The virus, etc.?From studies on the virus in recent years has emerged a composite group, the
Lansing type (from Lansing, Michigan, U.S.A.). including YSK and MEF. Immunologically, they are interrelated. The natural antibody titre of the human serum, against the type, increases with age. UltraIt consists of 4 strains
[Aug.,
1949
violet-inactivated Lansing virus and formalin-
Lansing virus are capable of mice and cotton rats. Active virus can immunize monkeys. Application of these processes to human beings has not so far been made (Rivers, loc. cit.). Probably they will Conprovide the only sure prophylaxis. valescent sera and anti-viral sera prepared in the horse are useless (Parish, 1948).
inactivated
immunizing
Points in epidemiology.?Lately communication between India and the Andamans has increased. Displaced persons, refugees and business men have gone to prospect. Many have returned. Most of them went from West Bengal and returned to or through West Bengal. The bearing of this movement on the reported incidence of poliomyelitis in India is not yet known. In England the disease is again approaching the incidence of 1947 which was rather heavy. From this increased and widespread incidence, including geographical tracts previously entirely free, it appears that a pandemic of poliomyelitis is in the making.
Prophylaxis, etc.?One single measure which be usefully directed against the disease is prevention of overcrowding such as occurs in cinemas, swimming pools, community bathing in holy waters and congregational worship under one roof. Fatigue and chills must also be avoided. But unfortunately it must be added that prophylactic measures have failed singularly in checking the disease (Editorial, 19496). On the other hand it has been feared that a high standard of living and superior sanitation make the community concerned more liable (Horstmann, 1948). The fear caused by this observation has been allayed recently (Hill and Martin, 1949). A very significant observation against infection by droplets has been made : the disease in England shows a high incidence in autumn when other infections caused by droplets show a low incidence (Editorial, 1949a). Exclusion of flies, water and milk does not
can
appear to make any difference whatsoever. To add to the thorns of a thorny problem of poliomyelitis the hedgehog has crept in unexpectedly. Two animals were found in unusual places in England. One of them was paralysed. The other which was not paralysed has left behind dried spoor which is awaiting investigation (Wilson, 1949; Spicer, 1949). Moles have been suspected for some time as natural reservoirs of the disease. They, cotton rats and Swiss mice have been infected experimentally (Rector, 1949; abstract on p. 370). Emboldened by the defeat of the epidemiologist a non-medical observer in England has suspected peaches for the following reasons.: (1) During the War when peaches were not available there was little evidence of infantile paralysis. (2) After the War when peaches were placed on the market the incidence of the
Aug., 1949]
POLIO
:
VISWANATHAN
and rose. (3) Peach skin is furry porous, unlike that of an apple, which is hard and smooth and can be cleaned better. (4) In Canada, incidence is said to increase every year when peaches are ripe (Maddison, 1949). The peaches, fresh and tinned, may be avoided as well. Peach jam may be safe.
disease
the virus in India. improvement occurs in the Paralysis up to a year has been considered to he an evidence of the chronic nature of the mfection. If the polio scare is found to be correct (by an increased incidence of the disease) and the damage negligible (as is usual, so far), the correctness of the adverse tellural influence on the virus in India will have been proved. That will suggest the utility of tellural hospitals in India for the treatment of cases of polio contracted in Europe and America (Greval, loc. cit.).
Adverse
tellural
?The fact that
influence
on
REFERENCES Brit. Med. Jour., 20th Aug., ii, 406. Calcutta, Statesman, The Chand, A. (1949) 5th Sept., p. 1, col. 6. The Medical Press, 31st Aug., Editorial (1949a) 222, 89. Brit. Med. Jour., 6th Aug., Idem (1949b) ii, 323. Greval, S. D. S. (1946). Indian Med. Gaz., 81, 254. Hill, A. B., and Martin, Brit. Med. Jour., 13th Aug., W. J. (1949). ii, 357. Horstmann, D. M. The Lancet, i, 273.
Caughey,
J. E. (1949)
..
..
..
..
(1948).
Hyman,
H. T (1946)
Kilham, and
Integrated Practice of Medicine. W. B. Saunders Philadelphia Company,
An
..
and London. 16th 934.
L., Levens, J., JA.M.A., J.
Enders, (1949).
Mackenzie,
F.
July,
Proceedings of the Royal Society of Medicine, July,
I. J. (1949).
42, 488.
Maddison,
Jean
(1949). Medical News (1949)
Medicine
(1948)
140,
E. Picture
Sept.,
..
..
Moses, S. H. (1948) National Health Service ..
Post,
London,
3rd
p. 48.
359. Indian Med. Gaz., 84, Science Newsletter, July 31, p 67 Indian Med. Gaz., 83, 355.
The Pharmaceutical Joumal, July, 85. (Questions to the ! Minister) (1949).
Parish,
H. J
Po-wel,
M. L. (1949)
Rector,
L. E. (1949)
Rivers,
T. M. (1948)
(1948)
..
Bacterial and Viral Diseases. E. and S. Livingstone,
Edinburgh. ..
..
..
The Med. Jour, of Australia, 6th Aug., 218. Abstract, Indian Med. Gaz., 84, 370. Viral and Rickettsial InfecJ. B. Man. of tions
Lippincott Company, Philadelphia, London and Montreal.
Spicer,
A. H. (1949) R. (1949). E. (1949)
Viswanathan, Wilson,
..
..
260. The Lancet, 6th Aug., ii, Indian Med. Gaz-, 84, 353. The Lancet, 6th Aug., ii, 260.
353
