Face Up 21 Strategy Card
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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-
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-