Onset Of Poliomyelitis Research Articles

Ultrasonographic evaluation of the distal femoral and talar cartilage thicknesses in patients with poliomyelitis: a cross-sectional observational study.

Sequelae of poliomyelitis, coupled with asymmetric impairment and weight-bearing, typically alter walking biomechanics which can be associated with the knee and ankle osteoarthritis. We aimed to investigate whether the distal femoral and talar cartilage thicknesses were different in patients with poliomyelitis. Cross-sectional observational study. Outpatients, tertiary care center. Thirty-six patients (12 males, 24 females) with a history of poliomyelitis and 36 age, gender and body mass index similar healthy subjects (11 males, 25 females) were enrolled. Mean values for age, body mass index and age of the poliomyelitis onset were 70.2±4.6 years, 27.2±5.7 kg/m2, and 3.6±2.4 years. Visual Analogue Scale (VAS) was used to assess pain. Lower limb muscle strengths were measured by manual muscle testing. The more affected side was identified according to the lower limb manual muscle testing. Bilateral distal femoral cartilage from the lateral femoral condyle, intercondylar area, medial femoral condyle and talar cartilage thicknesses were measured using ultrasound imaging. Among patients, the onset of poliomyelitis was at 3.6±2.4 years of age, and Functional Ambulation Category scores were 5 (3-5). VAS scores were similar between the sides affected more and less by poliomyelitis. All cartilage thicknesses (except the talar cartilage) of the patients were found to be thinner on the more affected side than the less affected side (all P<0.001). The thickness of talar cartilage was thinner compared to control subjects (P<0.001). Among the patients, quadriceps muscle strength was positively correlated with medial condyle (r=0.377, P=0.024), intercondylar area (r=0.399, P=0.016) and lateral condyle (r=0.363, P=0.030) thicknesses. Knee VAS scores were negatively correlated with talar cartilage thicknesses (r=-0.393, P=0.018). We found a thinning of the distal femoral condyle in the more affected paretic sides of poliomyelitis patients as compared to both those of less affected sides and those of healthy controls. Talar cartilages on both sides of the patients were thinner compared to control subjects. Our preliminary findings may contribute to the long-term management of patients with long-term poliomyelitis sequelae.

Diaphragm Dysfunction Due to Remote Poliomyelitis in a Patient With Unexplained Dyspnea

Late onset of new neuromuscular symptoms occurring many years after the initial illness is the hallmark of postpolio syndrome (PPS) [1]. In PPS, the new onset of motor weakness usually involves muscles that were previously affected; however, new symptoms also may occur in muscles that were clinically asymptomatic. This new weakness is thought to be due in part to overuse and excessive metabolic stress on the remaining motor neurons, eventually leading to their deterioration [1]. Respiratory compromise as a late feature of PPS has been reported and typically is associated with the following risk factors: history of ventilator assistance during the onset of poliomyelitis, central causes of hypoventilation, cranial nerve involvement, and/or musculoskeletal deformities [1-3]. Although respiratory involvement is seen in only a small minority of patients with PPS, it poses a potentially life-threatening complication that presents a challenge to those who manage it. We describe a patient with a history of remote poliomyelitis with no initial respiratory involvement who was evaluated at our clinic; he had a 3-year history of exertional dyspnea and an elevated left hemidiaphragm revealed on a chest radiograph.

Prevalence and risk factors of post-polio syndrome in a cohort of polio survivors

Objective To investigate frequency and associated factors of post polio syndrome (PPS) in an Italian cohort of people with prior poliomyelitis. Methods We screened subjects admitted for poliomyelitis at the paediatric hospital of the University of Palermo during the time frame 1945–1960. Patients who developed PPS were identified through a structured questionnaire and a neurologic examination. PPS diagnosis was made according to specified diagnostic criteria. Frequency of PPS was calculated in the selected cohort of polio survivors. The association with the investigated risk factors (sex, age at onset of polio, extension and severity of polio, education, associated diseases, cigarette smoking, trauma, polio vaccination) was analysed by the calculation of the odds ratio. Results Forty-eight participants met the adopted diagnostic criteria for PPS, giving a prevalence of 31.0%. The prevalence rate was significantly higher in women than in men ( p = 0.02). Logistic regression analyses revealed a significant inverse association with onset of poliomyelitis at over 12 months of age (OR 0.33; CI 0.14–0.79) a higher degree of education (OR 0.20; CI 0.07–0.79), and a significant association with the presence of other diseases (OR 9.86; CI 3.69–26.34). Conclusions In our survey one-third of patients with prior poliomyelitis had PPS. Higher age at onset of poliomyelitis is inversely associated with PPS. The association with other diseases may indicate that a chronic physical stress, particularly in already weak motor units, can contribute to the development of signs and symptoms of PPS. Our results also suggest the impact of socio-economic conditions on the risk of PPS.

Serum Creatine Kinase in the Post-Polio Population

Elevated creatine kinase (CK) levels may be noted in neuromuscular patients as a result of muscle damage and necrosis. We measured the serum CK levels of 62 post-polio patients with chronic neurologic disease (Neuro) and 13 post-polio patients with no evidence of neurologic compromise (Control). Patient groups were comparable for age, gender and years since onset of poliomyelitis. The Neuro group had substantially increased CK levels compared with the Control group, 211 +/- 19.0 IU v 114 +/- 26.2 IU (mean +/- 1 SE; P less than 0.05). Of the Neuro group, 40% had abnormally elevated CK values, compared with 8% of the Control group. Within the Neuro group, there was a robust correlation between elevated CK values and self-reports of strenuous work and level of community ambulation (P less than 0.05). These findings support the hypothesis that chronic muscle overuse may be a contributing factor to the advanced senescence reported by post-polio patients with neuromuscular compromise.

Interior-exterior bodily awareness following poliomyelitis.

16 permanently paralyzed patients and 17 recovered patients were asked “to name 20 parts of the body.” All Ss were tested late in the first year following the onset of poliomyelitis. The paralyzed patients showed statistically fewer interior responses while the recovered patients showed significantly fewer exterior responses than control groups matched on 7 variables. All groups made many more exterior responses (81%) than interior responses. This has been reported by others and should be kept in mind when investigating bodily attention patterns.

Into-Talus Transposition of Tendons for Correction of Paralytic Valgus Foot after Poliomyelitis in Children

An operation for the correction of paralytic, dynamic, valgus deformity of the foot of a child after poliomyelitis is presented. The procedure consists in the surgical mobilization of the medially and downward displaced talus, transfer of one or more of the deforming muscles (evertors of the foot) into the neck of the talus to maintain its corrected position, and, when necessary to correct equinus deformity, lengthening of the Achilles tendon. An analysis of the results in twenty-six operations and seven reoperations is presented. Into-talus transplantation seems to be best suited for the correction of paralytic, dynamic equinovalgus, valgus, and rocker-bottom deformities in children from three to six years old. If the procedure is performed on a foot with established changes in the shape of the tarsal bones, it may improve the shape of the foot, and hence contribute to more normal growth (Figs. 9-A through 9-F). When moderate displacement of the talus is present and the difference in strength of the so-called true invertors and evertors of the foot is not marked, only the extensor digitorum longus and the peroneus tertius—or better still, only a few slips of the common extensor—need be used for the transplantation. On the other hand, if the deformity is more pronounced, one or both peronei, or one peroneus with a part of the extensor digitorum longus, should be transferred. When the peronei are transferred to the talus, the direction of the pull is more from the lateral side than when the extensor digitorum longus is used. Accordingly, the peroneus longus and brevis should be used in feet in which the medial displacement of the talus is more accentuated (Figs. 10-B and 10-D). An additional advantage to using one or both of the peroneal muscles for the into-talus transplantation is that they contract automatically during the stance phase of gait and during push-off. The peronei may therefore be expected to pull the talus upward during weight-bearing and thus prevent its gliding medially off the calcaneus during the crucial phse of gait— when the talus bears the full thrust of the body's weight. This tendon transplantation should not be carried out concurrently with other tendon transplantations to the fore part of the foot, for reasons previously explained (Cases 7, 20, and 23). Transplantation of more than two muscles into the talus should be avoided, especially if it requires removal of muscles from the dorsum of the fore part of the foot, with resultant weakening of dorsiflexion. Reconstruction of the medial capsule of the talocalcaneal joint should be done only in those feet in which evertors, which are not transplanted, are observed at operation to have some shortening. Reconstruction of the medial capsule should not be done in feet in which all overtors have been transferred, because under these circumstances over-correction is bound to occur. The onset of poliomyelitis in the twenty-four children operated on occurred at an average age of one year and two months. The duration of follow-up averaged only two years and eight months—from one year and three months to five years and eight months. It is impossible at this time to predict what the effect of growth will be on the ultimate results. The preliminary results, however, seem to indicate that consideration should be given to the possibility of establishing direct, dynamic muscle control of the unstable talus from above before a decision is made to eliminate permanently the subtalar joint of a small child. It appears, in selected patients, that the establishment of so-called dynamic stability at the ankle joint may exert a beneficial influence on the subtalar joint and the joints of the middle portion of the foot to the extent that triple arthrodesis may be delayed with safety, or even not done at all.

The Chronology of Circulatory Changes in Poliomyelitis

1. Serial observations of cutaneous and muscle temperatures were made on patients with paralysis of one lower extremity only to ascertain the chronological appearance of changes in its peripheral circulation after the onset of poliomyelitis. 2. The data were subjected to statistical analysis for the determination of the significance of the alterations in circulation which were found. 3. Significant vasoconstriction in the skin of the paralyzed extremity was not present during the acute phase and appeared only after five to six months from the onset of the disease. 4. When vasospasm first appeared, it was minimal and sporadic; but after six months of the disease, the extremities of those with poor and fair muscles became consistently colder. The only exception in the distal portion of the extremity was the great toe which did not follow the circulatory pattern of the remainder of the extremity. 5. In the paralyzed muscle significant coldness appeared five to six months after onset of poliomyelitis in those groups with moderate and severe paralysis but was not present at any time in the group with mild paralysis. 6. Coldness of skin and muscle showed definite relationship to degree of paralysis.

The effect of therapeutic mobilization on hypercalciuria following acute poliomyelitis.

Hypercalciuria and extensive osseous demineralization predictably follow illnesses in which there is either flaccid or spastic muscle paralysis. In poliomyelitis, in particular, previous work in this laboratory 1 has demonstrated that there are two aspects in the mineral loss. During approximately the first three to eight weeks after the onset of illness, urinary calcium values rise to about twice the normal maximum of excretion. This rise is as marked in mildly paralyzed subjects as it is in patients suffering extensive muscle denervation; thus there is no direct quantitative relationship between the extent of paralysis and the degree of daily hypercalciuria in this early phase. During the period of from 2 to 12 months after the onset of poliomyelitis, however, the duration of hypercalciuria is directly related to the extent of paralysis. Excessive calcium loss may last as long as 40 weeks in patients with motor paraplegia, while quadriplegic subjects continue

Investigation of disturbances in blood flow following acute anterior poliomyelitis: A preliminary report

Eighteen patients with postpoliomyelitic involvement confined primarily to one lower extremity were subjected to plethysmographic studies in an attempt to confirm a clinical impression of vascular impairment in the involved extremity. The circulatory studies were not all consistent with the amount of shortening of the involved extremity. The authors believe that these inconsistencies are probably related to the time differential between the onset of poliomyelitis and the initial study. We do not believe that our results warrant any conclusions with regard to therapy, but we are planning and would encourage a similar study of cases of more recent origin.

Special indications for hypnosis as a method of anesthesia.

• The advantages of hypnosis as an alternative to conventional anesthesia in special instances are illustrated by accounts of five cases. In a pregnant woman about six weeks before term, the onset of poliomyelitis caused paralyses so extensive as to require tracheostomy and continuous respiratory assistance; when it was decided that labor should be induced, hypnosis was tried and found adequate for the delivery of a 2,664.9-gm. infant by low forceps. In a dental patient who had been insisting on general anesthesia after severe reactions to a local anesthetic, hypnosis solved the immediate problem and eventually diminished the patient's fear of dentistry. In a severe case of epilepsy, hypnosis sufficed for the craniotomy and excision of the epileptogenic focus in the temporal lobe after procaine was injected for the scalp incision. Hypnosis was found adequate similarly in a man who needed extensive debridement and grafting after thermal burns covering 45% of his body surface and in a girl who needed gynecologic surgery in the presence of severe congenital heart disease. The disadvantages of hypnosis, that it requires skill, is time-consuming, carries psychological risks, and fails in some subjects, are offset by its advantages in special cases. Its indiscriminate use in uncomplicated cases is not recommended.

Poliomyelitis in pregnancy: Effect on fetus and newborn infant

Summary 1.A prospective study was made of the outcome of gestation following the occurrence of poliomyelitis in New York City from 1949 to 1953, inclusive. During this period eighty-seven pregnancies, which resulted in eighty-eight products of gestation, were investigated. Sixty-five fetuses were associated with paralytic poliomyelitis during gestation and twenty-three with nonparalytic poliomyelitis. 2.There was no evidence of an increase in congenital defects, and inconclusive evidence of an increase in prematurity. 3.Fetal deaths were observed in from 35 to 46 per cent of the pregnancies complicated by the onset of poliomyelitis in the first trimester of gestation. Most of these fetal deaths were delivered within two weeks of the onset of clinical infection, and appeared to be directly related to the occurrence of poliomyelitis in the mother. 4.An increase in the incidence of neonatal poliomyelitis was observed which was associated with paralytic maternal infection shortly before delivery. 5.An increase in the neonatal mortality rate was noted which was related to neonatal poliomyelitis and to anoxemia following post-mortem cesarean section in women dying of bulbar poliomyelitis. Summary 1.A prospective study was made of the outcome of gestation following the occurrence of poliomyelitis in New York City from 1949 to 1953, inclusive. During this period eighty-seven pregnancies, which resulted in eighty-eight products of gestation, were investigated. Sixty-five fetuses were associated with paralytic poliomyelitis during gestation and twenty-three with nonparalytic poliomyelitis. 2.There was no evidence of an increase in congenital defects, and inconclusive evidence of an increase in prematurity. 3.Fetal deaths were observed in from 35 to 46 per cent of the pregnancies complicated by the onset of poliomyelitis in the first trimester of gestation. Most of these fetal deaths were delivered within two weeks of the onset of clinical infection, and appeared to be directly related to the occurrence of poliomyelitis in the mother. 4.An increase in the incidence of neonatal poliomyelitis was observed which was associated with paralytic maternal infection shortly before delivery. 5.An increase in the neonatal mortality rate was noted which was related to neonatal poliomyelitis and to anoxemia following post-mortem cesarean section in women dying of bulbar poliomyelitis.

THE APPARENT ABSENCE OF SIGNIFICANT PRIMARY VASOSPASM IN ACUTE SPINAL POLIOMYELITIS

Measurement of skin temperatures under controlled conditions can be used as an index of the state of the cutaneous circulation. During the first 40 days after the onset of poliomyelitis, there is no measurable alteration, based upon mean temperature values, in the cutaneous or deep circulation which can be attributed to the effects of the disease alone. What little change in circulation was found in the group of patients with poliomyelitis seemed to be similar to that produced by bed rest alone in a group of non-poliomyelitic patients.

ACUTE POLIOMYELITIS IN INFANTS UNDER ONE YEAR OF AGE: EPIDEMIOLOGICAL AND CLINICAL FEATURES

In order to compare the epidemiological and clinical features of poliomyelitis in infants under 1 year with those in children and adults, a study was made of all cases of poliomyelitis that occurred in New York City in 1949 and 1950. This revealed the following characteristics of the disease among infants in the first year of life: Clinically recognizable poliomyelitis was of infrequent occurrence among infants under 1 year of age. It was even more infrequent among infants in the first 6 months of life. This is in marked contrast to the findings in the 1950 epidemic in Israel, where one-third of all cases occurred in the first year of life, and one-tenth in infants in the first half year of life. Male infants exhibited a greater susceptibility to the disease than females. Fatalities in this age group were high, particularly among infants under 3 months, with some predominance of deaths in males. Under 1 year of age, non-paralytic poliomyelitis was unusual, especially in the first 6 months of life. Paralytic forms of the disorder were dominant, spinal involvement being more common than bulbar. Case fatality occurred chiefly in bulbar forms of the disease, as in older children and adults. The fatality rate was higher than in older children and higher than in all ages combined. The onset of poliomyelitis among infants under 1 year of age was variable. It was acute, with fever, or fever with nuchal spasm, or the triad of fever, nuchal spasm and spasm of back muscles. Temperature at onset of illness averaged 98.3°F.(36.8°C.), with a low of 97.6°F.(36.3°C.), and a high of 102°F.(38.8°C.). Temperatures recorded subsequently during the day of onset of illness were from 99.9°F. (37.7°C.) to 105°F.(40.5°C.), the mean being 102.8°F. (39.3°C.). The interval between onset of illness and first detection of paralysis averaged 5.5 days, with a spread from the day of onset to 25 days later. Paralysis of a single limb occurred more frequently than of 2 or more limbs, and the ratio of arm to leg paralysis was about 1 to 3. Initial spinal punctures in infants under 1 year were made on an average of 3.4 days after onset of illness in non-paralytic cases, and 5.7 days in paralytic cases. The spinal fluid was usually clear, with a mean count of 91 lymphocytes/mm. . The average sugar content was 55 mg./and protein 72 mg./100 ml. of fluid.

A CLINICAL EVALUATOIN OF TENDON TRANSPLANTATIONS FOR POLIOMYELITIS AFFECTING THE LOWER EXTRENMITIES

Any reported investigation would be remiss not to reiterate the general principles of tendon transplantation which have been carefully formulated by earlier observers. This study confirms many of these principles, and they are here recounted: 1. Proper selection of cases : It seems wise to wait at least twelve months, preferably from eighteen to twenty-fourr months, after the onset of poliomyelitis before tendon transplantation is considered. The passage of time will delineate the muscle strength of the individual muscle groups. Unless the deforming pull is a pernicious force, causing a rapidly progressive deformity, it seems inadvisable to transplant any tendon in a patient younger than five years of age. The proper selection of the tendons to be transferred, in regard to their strength, size, and anatomical position, is mandatory. 2. Correction of fixed deformities : Any existing deformity must be corrected, preferably prior to, or at least. concomitant with, the tendon transplantation, either by manipunlation, ligamentous procedure, or bone operation. 3. Adherence to standard operative plans and techniques : The operative plan should be simple. Complicated tendon transference and multiplicity of tendon transplantation should be avoided. The delicate handling of the tendon during the operative procedure with preservation of the peritenon and with transplantation to the new insertion through a tendon sheath seems highly desirable. The straight-line pull of the transferred tendon should be firmly anchored to bone, reinforced by the overlying periosteum, and with just the right amount of tension to hold securely the part in the corrected position. 4. Attention to postoperative fixation and care : This should be sufficiently long to allow firm fixation of the transplanted tendon to occur; at least three, and usually six weeks are necessary. 5. Attention to convalescent protection and care : Continued protection of the transplanted tendon by a suitable orthopaedic appliance worn during the day with a protective splint or a retention cast at night seems desirable for a six months' period. Protective shoe corrections for an additional six months will prove advantageous. Functional exercises for the transplanted tendon should be encouraged as soon as firm fixation has taken place and should be checked clinically at regurlar periods. The results of this clinical study seem to indicate that, with the exception of the group with tendon transplantations about the knee, in which objective improvement was slight, tendon transference, as performed in the region of the ankle and foot, particularly when combined with tarsal arthrodesis, is a feasible and successful orthopaedic procedure. It should be emphasized that the success of the procedure depends upon the proper selection of cases and the rigid adherence to the other criteria for tendon transplantation.

Development, persistence, and significance of type 2, poliomyelitis complement-fixing antibody in man.

Sera from 81 patients with a diagnosis of paralytic or non-paralytic poliomyelitis, and from 159 individuals of similar age groups giving no history of the disease, were tested with a high titered, complement-fixing poliomyelitis antigen of Type 2 (Lansing-like). The antigen consisted of brain tissue from newborn mice injected with the MEF1 strain of virus as previously adapted to these animals. The presence or absence of Type 2 neutralizing antibody in the sera under test was found not to affect the complement fixation. Positive reactions were obtained with 57 per cent of the sera deriving from non-paralytic patients and in 70 per cent from paralytics, when the specimens were tested at a dilution of 1:16. The complement-fixing antibody was often present in highest titer as early as 24 hours after the onset of poliomyelitis, and in almost all instances within 7 days. In about half of the patients a 4-fold or greater drop in titer occurred within 3 months, with little or no change in the others. The incidence of titers of 1:16 or higher with the control sera varied with the season of the year at which they were procured, 3 per cent of the winter samples proving positive and 13 per cent of the summer. The tests of sera from the group of patients from whom poliomyelitis virus was recovered, disclosed no significant differences between those having the paralytic and those having the non-paralytic disease. Type 1 (Brunhilde-like) strains of virus were recovered from many of the patients yielding positive tests, although they presented no evidence of previous or concurrent infection with Type 2 virus. This finding shows that Type 1 virus can give rise in patients to Type 2 complement-fixing antibody. The application of these data to the serologic diagnosis of poliomyelitis infection in man will of necessity be limited until information is obtained on the development, persistence, and significance of complement-fixation reactions with antigens deriving from Type 1 and Type 3 poliomyelitis strains.

Prophylactic immunization and poliomyelitis.

DURING the 1949 poliomyelitis epidemic in Melbourne, Australia, McCloskey 1 became interested in the relationship between poliomyelitis and immunizations. Frequently parents of poliomyelitis patients raised the question of whether an immunization against whooping cough or diphtheria shortly before the onset of poliomyelitis might have brought on the disease. McCloskey inquired into the history of immunization of 340 poliomyelitis victims. He found 31 children had been immunized within three months of onset. Paralysis was distinctly more frequent in the inoculated than in the uninoculated limbs. On more precise analysis of the time relationship, he found that the interval between the last inoculation and onset of symptoms ranged from 5 to 32 days in all except two of his 31 patients, whose interval was approximately 60 days. From the evidence collected, he concluded that there was a significant relationship in a number of cases between prophylactic injections and the subsequent development of

CORRESPONDENCE

The furor created by the reports of paralysis occurring in extremities injected with antigens in patients developing poliomyelitis within one month after the injection has assumed the proportions of hysteria. Anderson and Skaar (Pediatrics 7:741, 1951) clearly acquit "injections" given prior to one month before the onset of poliomyelitis of any recognizable part therein and certainly play no part in the etiology of poliomyelitis itself. The public and many public health authorities however are reacting to the serious detriment of the overall disease prevention picture.

POLIOMYELITIS

There is presented an analysis of the cases of poliomyelitis admitted to Children's Hospital, San Francisco, during a six year period in an effort to correlate this material with certain deductions regarding course, nature and the factors which affect the outcome. This series does not constitute a completely valid cross section of northern California epidemics because the admissions were modified by age, economic status, by a somewhat higher proportion of females, and by the fact that, in general, more severe cases were referred to this hospital from outlying districts. In addition to the physical traumatic factors which are generally admitted to be important in precipitating paralytic poliomyelitis, some evidence is introduced that systemic infections of unrelated etiology may provide a traumatic factor of comparable significance. In the biphasic febrile course of poliomyelitis the initial period of fever is rarely a matter of hospital observation and proof is usually completely lacking that this initial fever is certainly due to poliomyelitis virus. This preliminary rise in temperature may very well be due to other infectious agents which serve to precipitate the onset of poliomyelitis. There is much to indicate the considerable ubiquity of poliomyelitis virus among a population during an epidemic. In the absence of great exposure dosage, entrance of the virus into the body may frequently produce inapparent and completely latent infection which may be converted into active disease only by a variety of factors, including unrelated infections, which increase momentarily the susceptibility of the central nervous system of the host. The value of pooled irradiated human plasma in therapy is admittedly not very great but seems to have a certain value. Statistical demonstration in support of this is almost impossible because of the fact that a weakly effective agent is applied in the treatment of an infection which has an extremely variable outcome. This measure of treatment may displace the spectrum of outcome favorably without there being a great contrast in the statistical comparison of paralytic or nonparalytic outcome. Nonparalytic poliomyelitis is generally believed to be of frequent occurrence. Unquestionably this is more frequent with the inclusion of patients in which the diagnosis is based on minimal and unconvincing evidence. If the diagnosis is restricted to those cases with very definite clinical and laboratory findings, only a small proportion will completely escape paralysis though this paralysis may be minimal, may be detected only by careful and repeated examination, and may disappear entirely before the end of the two week period of hospitalization.

PERSISTENCE OF VIRUS EXCRETION IN THE STOOLS OF POLIOMYELITIS PATIENTS

It is now an established fact that many patients with acute poliomyelitis excrete virus in their stools, but little is known of the duration of excretion of virus in fecal material beyond the first four weeks of the disease. The literature up to 1940 has been summarized in two papers by Vignec, Paul and Trask. 1 An example of long persistence of the virus was reported in 1939 by Lepine and his associates, 2 who demonstrated it in the stools of a child forty-one, seventy-four and possibly one hundred and twenty-three days after the abortive disease. Since 1940 two late isolations have been reported: one by Howitt, Buss and Shaffrath 3 fifty days, and another by Wenner and Casey 4 fortyfive days after the onset of poliomyelitis. Piszczek and his associates 5 recovered virus from the stools of a healthy contact who had been exposed one and two months before

POLIOMYELITIS AFTER ADENOTONSILLECTOMY

To the Editor:— The subject of poliomyelitis following adenotonsillectomy is one of such importance that I submit the following tabulation of cases from the literature as a supplement to Dr. Felderman's letter in your issue of October 28. No case has been included in which the interval between operation and the onset of poliomyelitis was more than twenty-two days. The references will all be found in Stillerman and Fischer's paper ( Am. J. Dis. Child. 56 :778 [Oct.] 1938) except the one to the more recent paper of Koskoff, Amshel and Lebeau ( Arch. Pediat. 56 :19 [Jan.] 1939). The recent cases reported by Ayer and by Aycock are mentioned by Stillerman and Fischer as obtained by personal communication: As Stillerman and Fischer point out, the proportion of bulbar cases in poliomyelitis after adenotonsillectomy is so much higher than in poliomyelitis generally that the chances of its being accidental are statistically negligible