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man beings. Where the disease has been produced experimentally in monkeys, the incubation period has averaged about from eight to ten days, varying all the way from forty-eight hours to a month. In some patients the only noticeable symptom has been the discovery of a sudden paralysis, slight or severe in nature and varying in extent. In others some or all of ' the following symptoms may present — diar- rhoea, constipation, fever, headache, chill followed by profuse sweating, vomiting, restlessness, de- lirium, or apathy. Hypersesthesia over the entire body or any part of it is a most important symptom when present and an aid to early diagnosis. There may lie also pain in both the muscles and joints, which is increased at night. In some severe cases the temperature goes very high and remains so ; the prostration is extreme, unconsciousness may in- tervene, and convulsions may be present. In other cases we have any or all of these symptoms plus those which denote that the disease has also in- volved more than the spinal cord alone. The best face up 21 strategy card classification of the various manifestations of this disease is Wickman's, which is as follows: a, Or- dinary face up 21 online spinal paralysis or simple anterior poliomye- litis ; b, progressive paralysis, usually ascending, less often descending; Landry's paralysis; c, bulbar paralysis ; polioencephalitis of pons ; d, acute en- cephalitis, giving spastic monoplegia or hemiplegia ; e, ata.xic form ; f, polyneuritic ; multiple neuritic type; g, meningitic form; h, abortive form. Morse gives the following cases occurring in his practice as typical ones of these various divisions. Of division "a" it is hardly necessary to quote a case, as the majority of the cases occurring in any one's practice are of this kind. Type of class "b": The following history is a good example of the progressive type: Case I. A boy, ten years old, began to complain of pain in the legs .-Vugust iSth and by night was unable to walk without help. Pain and loss of power were rather more marked on the 19th. A physician who was called found a temperature of 102° F. and made a diagnosis of rheum- atism. The pain and fever continued. Pain and loss of power appeared in the arms on face up 21 chart .August 21st. The morn- ing of the 22d he began to have diftlculty in breathing and to have what were supposed to be convulsions. He rap- idlv became unconscious. Mict.irition and defsecation were \..ril 15, 191 ■.] STEINIIARDT: AXTERIOR PULlOESChPHALlTlS. both involuntary. lie wa$ moderately cyanotic. Respi- ration was short and gasping, but not very rapid. Frothy mucus ran from the mouth occasionally or was spat up with considerable difficulty. He was entirely unconscious. There was occasional twitching of the face. There was no rigidity of the neck The pupils were equal and re- acted to light. The chest was fully expanded and im- mobile; it was tympanitic on percussion. The abdomen was moderately distended and tympanitic. The diaphragm moved, but the excursion was very slight. There was a complete flaccid paralysis of all the extremities. The knee jerks were absent. Kernig's and Babinski's signs were also absent. He died a few hours later. Type of class "c" : The following cases are good examples of this type. The first belongs in the class which has in the past been called polioen- cephalitis superior, and the second in the class which has been called polioencephalitis inferior : C.\SE II. A boy, five years old, seemed a little out of sorts on August i6th.' The next day, while walking along the street, he fe!t weak, leaned against a fence, and vom- ited. He then walked a short distance, sat down in a chair on the piazza, and slept for half an hour. On wak- ing he was unable to walk because of staggering. The eyes were turned upward and remained in this position until the next day. He talked and seemed rational. He had no paralysis of the face or extremities. He twitched a good deal for several days and had cold sweats. The staggering gait lasted about a week. He complained at times of double vision. Strabismus was noticed about September ist. He was seen September igt\f. Physical examination was entirely negative except for complete paralysis of the left external rectus and partial paralysis of the right. The pupils were equal and reacted to light. The optic discs were normal. Case HI. A boy of five was taken suddenly sick with fever and vomiting July 26th. The vomiting and fever continued. He began to have difficulty in swallowing the morning of the sSth. and his voice became a little hoarse. When seen at 4 p. ni. he talked in a whisper and apparently had some trouble in swallowing. Examination of the mouth and throat, however, showed nothing abnormal. The neck was held rather stiffly. Nothing else was de- tected by a very careful general examination. The next day he was unable to swallow anything, even his saliva. When seen at 9 p. m. the whole of the right side of the face, including the forehead, was paralyzed. The tongue was protruded in the median line. The uvula could not be elevated. The pupils were equal and reacted to light. There was no strabismus and no stiffness of the neck. There was a complete paralysis of the exten.sor muscles of the right arm. The left arm and the legs were normal. The knee jerks were face up 21 blackjack present. Type of class "d" : The following case is a good example of this type and shows how difficult the di- agnosis is in this class of cases, which is more often than the others confounded with tuberculous menin- .gitis : C.\SE IV. A boy, three years old, fell down stairs, strik- ing his head, early in the morning of August 3d. He was apparently not hurt and appeared well all day. He began to vomit play face up 21 during the morning of August 4th and continued to vomit at intervals of about an hour until 3 a. m., August Sth. He did not vomit again. There had been no known indiscretion in diet, and the bowels were open. He was seen at 2 p. m., August sth. He was restless and irra- tional, but when roused noticed a little. There face up 21 free was no rig- idity of the neck and no neck sign. The pupils were equal and reacted to light. There was no spasm or paralysis. The knee jerks were equal and normal. The Kernig and Babinski signs were absent and there was no ankle clonus. The temperature was 99.8° F., the pulse 120, the respiration y(i. The rest of the phvsical examination and the urine showed nothing abnormal. The fluid obtained by lumbar puncture was under con- siderable pressure. It was at first clear and then some- what blf.o
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