predominance of lymphocytes. Sugar normal. 2. Isolation of virus - from nasopharyngeal swabs

rises to 100-200 mg. per 100 ml. during second week. Sugar normal. Cells 50-100, mostly polymorphs at first, later lymphocytes Rarely normal fluid. Signs - (a) Pulse fast and out of proportion to rise of temperature. (b) Excessive perspiration. (c) Patient is alert. 3. Paralytic stage - usually develops between 2nd and 5th days after onset of signs of involvement of nervous system. May set in without initial symptoms. Characteristics are - (i) Usually appears while there is still fever. (ii) Maximum at onset (iii) Distribution often asymmetrical. (iv) Usually begins within 1 to 5 days after onset of illness, progresses for 1 to 3 days, remains stationary for about a week and then shows rapid improvement for some weeks and then slower. (v) Absence of sensory loss DISTRIBUTION OF PARALYSIS - usually patchy, may produce monoplegia, paraplegia and quadriplegia. (a) Lower limbs - more frequently affected Usually quadriceps, tibialis anterior and peroneal group. (b) Upper limbs - most commonly deltoid. (c) Trunk -abdominal muscles, muscles of back, intercostals or diaphragm. (d) Respiratory disturbances - due to paralysis of diaphragm and intercostal muscles, or affection of respiratory centre in bulbar type - anxiety, increasing weakness of voice, cough, sucking in of epigastric or intercostal spaces with increasing use of accessory muscles of respiration, diminution in the numbers a patient can count after one inspiration, and cyanosis. 4. Convalescence - Initial paralysis usually diminishes to some extent after two or more weeks, and improvement may continue for several months. The affected muscles become flaccid whilst contraction will tend to produce severe deformities unless these are prevented. When chronic stage is reached six months to a year after initial infection, no further spontaneous improvement can be expected. Clinical types - Infection of a susceptible individual may result in one of 3 clinical manifestations - 1. Inapparent infection - in majority of cases. Does not progress beyond involvement of regional lymphnodes. However replication of virus in lymphoid tissue stimulates the immune system. 2. Abortive illness- occurs in 4-8% cases. Infection reaches viremic phase and foreign protein from virus is released into blood stream, as also endogenous pyrogens and other toxins from necrotic cells. This results in: (a) Abortive poliomyelitis - Presumptive diagnosis during epidemic Brief influenza-like illness with one or more of the following symptoms - malaise, anorexia, nausea, vomiting, headache, sore throat, constipation and localised abdominal pain. Fever seldom more than 103°F Coryza and cough uncommon. (b) Non-paralytic poliomyelitis - Subjective symptoms as in abortive type but headache, nausea, vomiting more intense, and soreness and stiffness of posterior muscles of neck, trunk and limbs. Fleeting paralysis of bladder not uncommon. 3. Paralytic poliomyelitis - (a) Spinal form - Paralysis of flaccid type usually asymmetrical and scattered in distribution, though more severe in one extremity Legs most frequently involved. Respiratory paralysis may result from involvement of diaphragm and intercostal muscles Transient bladder involvement in some. (b) Bulbar form - Muscles supplied by bulbar nuclei involved alone or with spinal musculature. Facial, palatal and sometimes pharyngeal paralysis causes change in voice, difficulty in swallowing, nasal regurgitation and choking when attempting to drink. Respiratory paralysis is the usual cause of death. Diagnosis: 1 CSF -Increased white cell count (usually below 500/mm3), often with high polymorph count in first few days followed by predominance of lymphocytes. Sugar normal. 2. Isolation of virus - from nasopharyngeal swabs during the first 5 days of illness only, but from stools and rectal swabs containing faecal material upto 5 weeks after onset. 3. Serology - A fourfold rise in level of antibody to the strain of virus isolated. Differential Diagnosis - Initial prodromal phase - (a) Infections of respiratory tract - Coryza, tonsillitis, bronchitis, influenza. (b) Gl disorders - Gastro-enteritis, rarely acute appendicitis. Preparalytic phase - 1. Viral (aseptic) meningitis - Rigidity more marked and persistent. Headache more severe Consciousness not clear. Hyperaesthesiae not prominent. Paralysis of limbs rare and occur late. C.S.F. clear or slightly turbid with upto 1000 cells per c. mm. usually lymphocytes 2 TB meningitis - Insidious onset. Previous ill health. Slow respiration. Flaccid paralysis uncommon. Ocular palsies. 3. Encephalitis - (Refer). 4. Conditions with tenderness of limbs - e. g. acute rheumatic fever and infection of bones, joints and muscles. No abnormal nervous signs. CSF normal. No true paralysis Paralytic stage - 1. CONDITIONS CAUSING PSEUDOPARALYSIS - (a) Rickets - enlarged epiphysis, beading of ribs, frontal bossing., diagnostic X-ray. (b) Scurvy - Swelling of limbs with extreme tenderness. Swollen and bleeding gums. (c) Syphilitic epiphysitis - occurs early in life. Other signs of congenital syphilis. Positive serology. X-ray changes. (d) Acute osteomyelitis - child may not move limb because of pain Diagnosis by X-ray. (e) Unrecognised trauma - e.g. contusion, sprain, fracture. 2. CONDITIONS CAUSING MUSCLE WEAKNESS - (a) Guillain-Barre syndrome - Paralysis commences in legs and rapidly ascends. No hyperaesthesia, often