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POLIOMYELITIS
901
Special
Articles
We sometimes had occasion to regret having made a even to readmit patients who had been prematurely discharged from other centres. It has been our experience that, except when pressure on beds makes it necessary to use isolation cubicles for their primary purpose only, the need for transfer is negligible when the fever unit works in close liaison with general beds cared for by the same orthopaedic and physiotherapy staff, and we now retain our patients until their final discharge home. The advantages to them in remaining under the same supervision throughout are obvious. The problem is cumulative. Current work includes the victims of the epidemics of the past few years as well as the fresh cases. As with another major medicosocial problem, that of pulmonary tuberculosis, the solutionor at any rate a provisional solution-lies in bringing these patients back into the atmosphere of the general hospital. Here the fever hospitals, now largely overbedded for their original responsibilities, thanks to the improvement in the public health, may play an important part. I agree with James (1951) that these hospitals, largely deprived of their clinical bread-and-butter, by the decline in diphtheria and scarlet fever, should now be used as general hospitals. James thinks in terms, of a cubicled fever unit, in the charge of a physician experienced in fevers, embedded in a general hospital with provision for pathology, radiology, and surgery. He finds that this arrangement works well, that the catholicity of the experience retains medical staff of good calibre and student nurses who might otherwise drift away, and that the greatest benefit is to the patient. This is the same as the set-up at Brook Hospital ; it has worked very well, and is ideal for the city victims of infantile paralysis.
transfer, and
POLIOMYELITIS Some fin-de-saison Reflections
DAVID LE VAY M.S. Lond., F.R.C.S. ORTHOPÆDIC SURGEON, BROOK GENERAL HOSPITAL, LONDON "
There is no question that a lot of treatment (for poliois still being given undue credit which rightly belongs to the Lord, and not to any orthopaedic surgeon or physiotherapist. I would not go so far, however, as to say that any sort of treatment ... is useless " (Steindler 1947).
myelitis)
IT seems likely that major epidemics of infantile will recur annually in this country in future, and that we shall have to face the situation-which has already existed in North America for a long time-that each succeeding year brings many thousands of fresh cases, a considerable proportion of which are paralytic. In the past, when cases were fewer, it was usual for patients to be retained in fever hospitals until the end of an arbitrary quarantine period, after which, if there was any severe residual paralysis, they were transferred to long-stay orthopaedic units. In view of the trend of the disease these arrangements may now be open to criticism. In some cases there may be little or no useful " physiotherapy and orthopaedic supervision during the all-important early quarantine period, when overstretching and contracture begin ; the patient’s later stay under definitive orthopaedic care may be remote from. home and family and the main stream of town life; and, as one consequence, practical experience in the management of infantile paralysis is lacking in the ordinary urban hospitals, which may now, as the burden increases, have to take their share of this work. Such criticism is admittedly by no means everywhere applicable. The system is a natural one and has so far worked fairly well. As Clarke (1950) says of orthopaedic work in general, a city hospital... is unsuited for the treatment of chronic illness. The role of these hospitals is to act as after-care clinics for the collection, treatment, and supervision of outpatients.... It is important therefore that close working liaison should be established between town and country hospitals." But this is a counsel of perfection. We are already hard pressed for hospital beds and services, partly because of the demands made on urban hospitals for the care of the chronic sick and the aged. If changes are needed in the immediate future, so far as poliomyelitis is concerned, one reason will be that too few beds are available, when wanted, in the oldestablished peripheral orthopaedic hospitals. It is vital to ensure that young and valuable members of the community are not discharged prematurely to their homes for lack of those inpatient orthopaedic and rehabilitation facilities which are still by no means readily found even for early cases of skeletal tuberculosis. I view this matter in the light of the experience of the management of nearly 200 cases of poliomyelitis, of which 140 were paralytic, at the Brook General Hospital during the last three years. Until July 5, 1948, this was’purely a fever hospital, but since then it has become a general medical and surgical hospital containing a modern fever unit of 130 beds. It was felt that the tradition of early admission to fever hospital and subsequent transfer to a long-stay centre should be abandoned, partly because it became increasingly difficult to obtain places in those institutions when they were wanted, but more because the continuity of treatment was broken by such transfer. Only 25 of our patients were so transferred, largely because of overwhelming pressure on beds at the height of the epidemic season, or because of the need of education in long-term cases in children, or because special facilities, such as large-pool therapy, were thought desirable.
paralysis
"
,
Treatment The routine after admission is for all poliomyelitis patients to be nursed flat on fracture boards. Children and light young adults have no pillow or mattress and only four folded layers of blanket over the boards; most adults have a hair mattress and one small pillow. A pad behind the knees prevents hyperextension, and bed cradles and sand-bags keep the feet from dropping. When the deltoid muscles are obviously affected, the arms are fixed with cuff and bandage to the upper bed-rail to hold the shoulders abducted. Preliminary muscle charting is done as soon as possible, but may be postponed for a few days if need be. It is an ordeal in the acute case, and we are reluctant to require any activity which may worsen the paralysis during the early days ; even lumbar puncture is not done when the diagnosis is obvious. It is realised that this first chart may not be a fair guide, since cooperation is not good when pain and spasm are present ; the real startingpoint may not be obtained until several charts have been made at intervals of a few days and the patient has made a good effort to cooperate. After this, charting is done every three or four weeks. There is no need here to emphasise the cardinal importance of obtaining some sort of chart, however sketchy, if any idea of progress is to be formed ; it is the compass which enables one to guide the patient from stage to stage of his journey. With tiny children chart-making may require infinite patience, perhaps limited to quietly sitting and watching their activities. splints SPLINTS
In general we think it better to use too few splints than too many, (1) because efficient daily physiotherapy will prevent contractures, and (2) because oversplintage tends to deprive small children of the sense of the use of their limbs. When splints are used they are removed for long periods by day so that the .patient can do what he likes with his muscles. ’The main indications for light plaster splints are to maintain abduction for deltoid paralysis in infants who
902 so much that mere tying of the arm to the bed does not suffice, and to hold the foot at a right angle. "1,’ 1 ..... -- 1.-. - - 1 - _L": elastic J<; is ew 11 er e, splints are used where necessary-e.g., the thumb can be comfortably supported in opposition with ’Elastoplast,’ when the opponens muscle is paralysed, allowing the first web space to be stretched regularly. Little is to be gained by the use of
wriggle
.....
long arm or leg splints. If one wants to hold
an
elbow at
right angles, this can be done efficiently with a collar-and-cuff, and in the legs it is enough to see that the popliteal pad prevents full extenFig. I-Wooden cross-bar incorporated in sion. We have been foot splint to prevent external rotation of lower leg. impressed with thee importance of seeing that external rotation of the leg does not produce a chronic strain of the internal lateral ligament of the knee, as may happen insidiously in a flail lower limb when the foot and leg fall outwards. As Yachnin (1947) points out, the axis of rotation at the knee is inside the midline of the joint, and the main mass of the limb outside ; the joint is more lax when its supporting muscles are paralysed, and when the lower limb falls into external rotation from the hip downwards it is the portion below the knee which rotates abnormally. This rotation strains the internal ligament and may become permanent, with severe pain and stiffness which may persist for a year or two. ’ Such a deformity is easily prevented by incorporating a wooden cross-bar in the foot splint (fig. 1). When a limb is completely flail, and careful repeated observation shows not the slightest sign of recovery, the splint is discarded and reliance placed merely on passive movements to prevent stiffness and to preserve the propriocoption which will be needed later for walking in a calliper. But such writing off must be done with caution. The deltoid muscles in particular show amazing powers of recovery, which may never take place if the small spark of power is allowed to be extinguished by overfatigue. PHYSIOTHERAPY
This is
begun
at once, with the
following provisos :
(1) in the very ill patient and in the earliest days it is probably harmful to interfere ; and (2) it must be remembered that some cases will continue to deteriorate during the first few days after admission. Patients with only mild scattered paresis on the day of admission may develop flail limbs in a few days and be in the respirator by the end of the week. Lenhard (1950) says : " Treatment for the poliomyelitis patient is commonly translated into an urge to do something.... The more that is done for the patient, the better the therapist feels. The greatest need in the early stage is rest for the patient and the muscles involved ; they do not require, nor should they have, much physical therapy."
This is true enough, but it is also true that there is an essential minimum of treatment which these patients must have. We usually begin treatment before the end of the first week, and at once in those cases where the patient has been ill at home for some days before admission and is obviously ready to recover. Only so much
attention is given as is needed to keep the joints mobile, and all joints are given a full passive range once daily. If every plane of movement is not kept in mind, unexpected contractures may develop-e.g., abduction contracture of the hip, with adductor paralysis. TREATMENT OF PAIN AND SPASM
The obstacles to daily movement are pain and spasm, not always, found in association. What is the source of this pain ?Though it is difficult to answer this question for every patient, we may
usually, though
recognise : 1. Painful spasm in the unparalysed or partly of completely paralysed muscles.
paralysed
antagonists
2. Pain due to stretching of the posterior muscles—calves, hamstrings, and erectores spinsc—which are in spasm as part of the meningeal reaction. This is not necessarily related to the onset of paralysis and is often most severe in cases which ultimately recover completely. 3. Pain arising from the joints and their ligaments, and ---4 *--""......1,.........", nnn.., ,..... r."..,.............
been relaxed
by drugs.
4. Secondary pain due to strain of ligaments from the position of paralysed limbs. 5.
over-
faulty
Perhaps pain of central origin
due to inflammation in the sensory roots and ganglia. Against this, however, is the fact that the
and
‘
patient rarely feels pain while lying perfectly still and undisturbed.
Spasm 1.
embraces:
Spasm completely
of the or
antagonists of partly paralysed
muscles.
Fig. 2-Sling-and-spring suspension from ceiling for gross paralysis of lower
2. Primary meningitic spasm of calves and hamstrings, not necessarily related to paralysis. 3. A much rarer form occurring during the progress of a limb muscle to complete paralysis. We have had only a few cases, always in the quadriceps, where the muscle, capable of little or no active contraction, feels indurated to the touch and gives the sensation of fine fibrillary contractions for 24-48 hours before it becomes soft and functionless.
However troublesome pain and mav be. thev must not be allowed to obstruct daily passive movements. Firmness on the part of the physiotherapist is essential -a single decisive movement may stretch the hamstrings where more timid attempts fail-but it may be necessary to obtain assistance from drugs. Curare in sufficient dosage will usually relieve most of the spasm and has been vigorously recommended by Dr. N. S. Ransohoff in New Jersey (Lancet 1948) ; but it does not simultaneously relieve the pain. Even when the patient has been reduced to flaccidity, movement may remain agonising, and therefore we cannot regard curare as a suitable aid to therapy, apart from its undoubted value in relieving urinary retention due to spasm of the limbs in
an
adult.
snasm
sphincters. ’
Priscol’has been reported on with enthusiasm by Smith et al. (1950) in New York, but we have not found it of great value, and its effects are less dramatic than those of curare. Intravenous procaine, in our hands, has also had only an uncertain effect on pain and spasm, even in large
dosage. The veins of small children are not always suited to the administration of these drugs, and the well-established relation between intramuscular injections and the site
903 of paralysis in closely following poliomyelitis is a. contraindication to intramuscular injections in the acute phase of the disease. We prefer not to give them except into the muscles of completely flail limbs. However, the problem of really serious pain and spasm is not a serious one in this country, where poliomyelitis seems in this respect to differ from the American variety. Thus Smith et al. found priscol valuable because it relieved the nurses of the arduous duty of renewing the hot packs in most of his cases. Not more than perhaps 10% of our cases are troubled with really severe pain and spasm, and by far the best method of obtaining full motion in such cases is under temporary analgesiaanaesthesia induced with rectal thiopentone or with gas-and-oxygen. Patients in respirators must still be taken out daily for treatment while breathing is maintained with an anaesthetic machine, and this is often just the type of case with the greatest pain. .
TREATMENT DURING RECOVERY
Once. the painful stage is over, or not too troublesome, all the children have daily massage and mobilisation for the back, where rigidity may develop even in nonparalytic cases. As recovery proceeds, passive movements give way to assisted active movements, and then to progressively more active exercises against resistance. Whenever there is gross paralysis of the lower limbs, return of power in the gluteal and adductor groups is encouraged by sling and spring suspension from eyelet hooks screwed 18 in. apart in the ceiling over the bed (fig. 2) ; in the case of young children, these can be attached to double Balkan beams slung across the cotrails (fig. 3). Patients on slings must be taught to perform single deliberate movements with a pause between each phase, or the mere recoil inertia of the apparatus will give the illusion of recovering power. The heels need be only just clear of the bed, and then the glutei maximi muscles can be exercised by forcing the feet down on the covers ; if these muscles are too weak for this, the patient is turned on his face in the slings for part of the day, so that the springs assist the movement of hyperextension at the hips. As the glutei medii recover, the apparatus can be loaded against them by incorporating a cross-spring to make abduction more difficult (fig. 2) or by weighting the slings with shot. It is important
that the exercises should not progress in activity too rapidly, but it is also important to keep slightly ahead of the patient’s capacity. The sling and springs can also be used for the shoulder if fixed to the overhead bed pulley when the patient has reached the three-pillow
stage (fig. 4).
’
INSTRUMENTATION
Future needs for surgical appliances are foreseen as far as possible, and these are ordered well in advance. We prefer to tend to over-instrumentation and then are prepared to shed part or all of the appliance when it The patient who -is becomes clear that this is safe. beginning to get up and about, whether or not with the help of a calliper, is watched more carefully, and charted
mnrn
often
+n
ensure
that trunk and hip muscles do not deteriorate under the strain. If they are evidently holding their own, he is sent home after a few weeks. When patients require tendon transplantation or foot-
stabilisation operations they are admitted to the surgical wards of this or an associated local hospital, and after operation they return to the unit in plaster. It is important to watch even apparently non-paralytic patients for a time in the follow-up clinic, because previously undiscovered weaknesses of spinal and
trunk muscles may not become obvious for some time. Since this hospital Fig. 4-Sling-and-spring susdraws its poliomyelitis cases pension from bed pulley for paralysis of shoulder largely from a geographically muscles. small but denselv populated sector of London,. many patients live within quite a short distance. We have found it an enormous advantage to be able to follow these cases through in close touch with parents and home conditions ; it is possible to train them in hospital to deal with replicas of the physical difficulties they will have to surmount at home, to prevent any overfatigue-or overprotection-in the family circle, and to watch over rehabilitation and return to work in consultation with the local resettlement authorities. Possibilities
The only reasonable outlook for the therapist in poliomyelitis is one of sober pessimism. No-one can yet cure
Fig. 3—Sling-and-spring
suspension from Balkan paralysis of lower limbs in a child.
beams
for
gross
the disease, and it has been said that the end-result after ten years is the same whatever treatment-or if no treatment-is given. While this saying may be true in so far as the sum total of potential recovery is concerned, it overlooks the fact that even this potential will not be realised if careless management allows contracture and fatigue to prevent the orderly development of what muscle power exists. It is common for a missed case not to be admitted to hospital until some weeks after the acute stage, when prompt improvement occurs in muscle groups relieved from overstrain. Would such improvement have taken place without treatment ? However pessimistic in private, we must be uniformly optimistic in encouraging the patient to make the fullest use of what he possesses, and should err in the direction of the mildest of bullying to prevent self-pity and keep his capacities fully extended. It is a mistake, for instance, to order a wheel-chair at an early stage for any young adult before he has explored to the limit his capacity to get about unaided and has found a job.
904
poliomyelitis is dominated by the rapid Mr. A. B. Taylor of the Department of Health for of irreversible changes produced by’ the Scotland) were common to all eight committees, and with the secretary (Mr. T. C. L. Nicole) they have virus in the a,nterior-horn cells of the cord. Though specific common to all antibiotics may well be discovered, there will still remain prepared the main report on " matters the problem of diagnosing poliomyelitis and exhibiting types of medical auxiliary service."1 This is followed by the reports of the eight committees. Nearly all the the antibiotic in the few hours or days before these take In the classical place. permanent changes descrip- members of these committees have approved the main tion, the paralysis of this disease is fully fledged at the report as well as their own, hut there are three outset ; but we have been greatly impressed by the minority reports expressing dissent. number of cases which enter hospital without any paraSUPPLY AND DEAIANI) at all, or only mild paresis, and then go steadily downhill during the next few days. Apart from actual In the main report a distinction is made .between death of neurones from virus toxicity, at least part of need " and " demand." By "need" is meant the the damage must be due to inflammation within the cord numbers required by the N.H.S. to give the public a, -the perivascular cuffing, oedema, and glial infiltration. full service in all parts of the country. Demand," These must be potentially reversible, and Steindler (1947) on the other hand, is defined as the number of vacancies that employing authorities are likely to seek to fill at goes so far as to postulate the essential reversibility of the lesions in the anterior-horn cells : " Up to a certain present or, say, within the next five years. Just as many different factors may limit demand, point the changes seen in these cells must be reversible, just as the inflammatory glial infiltration and the peri- many other factors may limit supply. Most entrants vascular lymphocytic exudates are reversible." to the medical auxiliary services are drawn from those This seems to offer hope for the future, now that we who pass the School Certificate or some equivalent are beginning to learn how to control the body’s response examination. From this pool come nearly all entrants to injury. It was natural to useCortisone’ and adrenoto the professions and a wide range of executives, corticotropic hormone (A.C.T.H.) in the hope of arresting secretaries, and technical staff in the public services. these disabling vascular responses to infection within the and businesses. Any gain in recruitment in one auxiliary cord, since these substances act to a considerable extent service is likely to be made at the expense of recruitment by preventing just this defence reaction in other tissues. in another auxiliary service-or in some other occupation Though a very thorough trial of A.C.T.H. by Coriell et al. which may be of national importance and already under(1950) showed no improvement whatever in paralysis manned, such as teaching or nursing. or in mortality over untreated controls and though In some of the medical auxiliary services demand cortisone produced a severe exacerbation of experimental exceeds supply, and the professional associations may infections in animals (Schwartzman 1951), it may still seek, severally and independently, to expand their ranks in order to meet it. Such competition may defeat itself, prove somehow possible to reverse the inflammation within the cord, and work should continue along these lines. and there should therefore be some means of coordinating the relation of supply to demand over the whole medical It is a great pleasure for me to acknowledge the devoted care my patients have received from Miss May Cooke, c.s.p., auxiliary field. " The problem of supply is not one of physiotherapist-in-charge, because the skill and personality meeting all requirements of all kinds as soon as possible, of the physiotherapist are far more important in poliomyelitis but of advising on a balanced programme of recruitment than anything the doctor can do. Both of us have had every over a period of time so as to try to spread the available possible help and encouragement from Dr. John Armstrong, man-power over the medical services to the physician-superintendent of Brook Hospital. best advantage." REFERENCES Though salaries were not mentioned in the terms of the report saysthat men and .women entering reference, Clarke, H. O. (1950) J. Bone Jt Surg. 32B, 631. Coriell, L. L., Siegel, A. C., Cook, C. D., Murphy, L., Stokes, J. the auxiliary services should be assured of salaries and, jun. (1950) J. Amer. med. Ass. 142, 1279. so far as possible, of prospects of promotion, similar to James, E. (1951) Lancet, i, 290. Lancet (1948) i, 254. those of occupations with comparable standards of Lenhard, R. E. (1950) J. Bone Jt Surg. 32A, 71. training. In particular " account should be taken of Schwartzman, G. (1951) New York Times, int. ed. suppl. Jan. 28, p. 7. Smith, E., Graubard, D. J., Falcone, J., Givan, T. B., Rosenthe effect of salary scales upon recruitment of both men blatt, P., Feldman, A. (1950) J. Amer. med. Ass. 144, 213. and women when the supply is below the demand.... Steindler, A. (1947) J. Bone Jt Surg. 29, 59. Yachnin, S. C. (1947) Ibid, p. 415. The outlook in
development
lysis
"
auxiliary
TRAINING
MEDICAL AUXILIARIES IN THE N.H.S. REPORTS OF THE COPE COMMITTEES
Two years ago the Minister of Health and the Secretary of State for Scotland set up eight related committees to consider the supply and demand, training, and qualifications of the following groups working in the National Health Service : Almoners
Chiropodists Dietitians Medical laboratory technicians
Occupational therapists Physiotherapists (including remedial
gymnasts)
Radiographers Speech therapists
of members agreed to accept the term " medical auxiliaries " as a designation for these groups, accepting the view that " however different their duties may be, all medical auxiliaries in the National Health Service have this in common-they work for the benefit of the patient under the direct or indirect supervision of the doctor." The chairman (Mr. V. Zachary Cope, y.R.c.s.) and two members (Dr., G. A. Clark of the Ministry of Health, and
The
majority
some of the services covered fall into groups, either because several types of auxiliaries work, together asa team under a hospital consultant or because of affinities in the work done. Thus on the one hand there is a rehabilitation group " consisting of physiotherapists, occupational therapists, and remedial gymnasts, and on the other there is a medical-social group which includes almoners with others (outside the terms - of reference) such as psychiatric social workers. Dietitians and cannot be with others. chiropodists readily grouped The committees sympathise with the view that there should be some common training in basic sciences for some auxiliaries, or at least for those in each distinguishable group ; but they note practical difficulties. For example, in certain basic sciences, such as anatomy and physiology, the same syllabus will not serve equally well for the speech therapist, the chiropodist, the radiographer, and the physiotherapist. Nevertheless the possibility of a common basic course should be kept in mind, especially when new training-schools are being "
1.
Reports of the Committees on Medical Auxiliaries, Cmd. 8188 1951. Pp. 227. 5s. H.M. Stationery Office.
Special
Articles
We sometimes had occasion to regret having made a even to readmit patients who had been prematurely discharged from other centres. It has been our experience that, except when pressure on beds makes it necessary to use isolation cubicles for their primary purpose only, the need for transfer is negligible when the fever unit works in close liaison with general beds cared for by the same orthopaedic and physiotherapy staff, and we now retain our patients until their final discharge home. The advantages to them in remaining under the same supervision throughout are obvious. The problem is cumulative. Current work includes the victims of the epidemics of the past few years as well as the fresh cases. As with another major medicosocial problem, that of pulmonary tuberculosis, the solutionor at any rate a provisional solution-lies in bringing these patients back into the atmosphere of the general hospital. Here the fever hospitals, now largely overbedded for their original responsibilities, thanks to the improvement in the public health, may play an important part. I agree with James (1951) that these hospitals, largely deprived of their clinical bread-and-butter, by the decline in diphtheria and scarlet fever, should now be used as general hospitals. James thinks in terms, of a cubicled fever unit, in the charge of a physician experienced in fevers, embedded in a general hospital with provision for pathology, radiology, and surgery. He finds that this arrangement works well, that the catholicity of the experience retains medical staff of good calibre and student nurses who might otherwise drift away, and that the greatest benefit is to the patient. This is the same as the set-up at Brook Hospital ; it has worked very well, and is ideal for the city victims of infantile paralysis.
transfer, and
POLIOMYELITIS Some fin-de-saison Reflections
DAVID LE VAY M.S. Lond., F.R.C.S. ORTHOPÆDIC SURGEON, BROOK GENERAL HOSPITAL, LONDON "
There is no question that a lot of treatment (for poliois still being given undue credit which rightly belongs to the Lord, and not to any orthopaedic surgeon or physiotherapist. I would not go so far, however, as to say that any sort of treatment ... is useless " (Steindler 1947).
myelitis)
IT seems likely that major epidemics of infantile will recur annually in this country in future, and that we shall have to face the situation-which has already existed in North America for a long time-that each succeeding year brings many thousands of fresh cases, a considerable proportion of which are paralytic. In the past, when cases were fewer, it was usual for patients to be retained in fever hospitals until the end of an arbitrary quarantine period, after which, if there was any severe residual paralysis, they were transferred to long-stay orthopaedic units. In view of the trend of the disease these arrangements may now be open to criticism. In some cases there may be little or no useful " physiotherapy and orthopaedic supervision during the all-important early quarantine period, when overstretching and contracture begin ; the patient’s later stay under definitive orthopaedic care may be remote from. home and family and the main stream of town life; and, as one consequence, practical experience in the management of infantile paralysis is lacking in the ordinary urban hospitals, which may now, as the burden increases, have to take their share of this work. Such criticism is admittedly by no means everywhere applicable. The system is a natural one and has so far worked fairly well. As Clarke (1950) says of orthopaedic work in general, a city hospital... is unsuited for the treatment of chronic illness. The role of these hospitals is to act as after-care clinics for the collection, treatment, and supervision of outpatients.... It is important therefore that close working liaison should be established between town and country hospitals." But this is a counsel of perfection. We are already hard pressed for hospital beds and services, partly because of the demands made on urban hospitals for the care of the chronic sick and the aged. If changes are needed in the immediate future, so far as poliomyelitis is concerned, one reason will be that too few beds are available, when wanted, in the oldestablished peripheral orthopaedic hospitals. It is vital to ensure that young and valuable members of the community are not discharged prematurely to their homes for lack of those inpatient orthopaedic and rehabilitation facilities which are still by no means readily found even for early cases of skeletal tuberculosis. I view this matter in the light of the experience of the management of nearly 200 cases of poliomyelitis, of which 140 were paralytic, at the Brook General Hospital during the last three years. Until July 5, 1948, this was’purely a fever hospital, but since then it has become a general medical and surgical hospital containing a modern fever unit of 130 beds. It was felt that the tradition of early admission to fever hospital and subsequent transfer to a long-stay centre should be abandoned, partly because it became increasingly difficult to obtain places in those institutions when they were wanted, but more because the continuity of treatment was broken by such transfer. Only 25 of our patients were so transferred, largely because of overwhelming pressure on beds at the height of the epidemic season, or because of the need of education in long-term cases in children, or because special facilities, such as large-pool therapy, were thought desirable.
paralysis
"
,
Treatment The routine after admission is for all poliomyelitis patients to be nursed flat on fracture boards. Children and light young adults have no pillow or mattress and only four folded layers of blanket over the boards; most adults have a hair mattress and one small pillow. A pad behind the knees prevents hyperextension, and bed cradles and sand-bags keep the feet from dropping. When the deltoid muscles are obviously affected, the arms are fixed with cuff and bandage to the upper bed-rail to hold the shoulders abducted. Preliminary muscle charting is done as soon as possible, but may be postponed for a few days if need be. It is an ordeal in the acute case, and we are reluctant to require any activity which may worsen the paralysis during the early days ; even lumbar puncture is not done when the diagnosis is obvious. It is realised that this first chart may not be a fair guide, since cooperation is not good when pain and spasm are present ; the real startingpoint may not be obtained until several charts have been made at intervals of a few days and the patient has made a good effort to cooperate. After this, charting is done every three or four weeks. There is no need here to emphasise the cardinal importance of obtaining some sort of chart, however sketchy, if any idea of progress is to be formed ; it is the compass which enables one to guide the patient from stage to stage of his journey. With tiny children chart-making may require infinite patience, perhaps limited to quietly sitting and watching their activities. splints SPLINTS
In general we think it better to use too few splints than too many, (1) because efficient daily physiotherapy will prevent contractures, and (2) because oversplintage tends to deprive small children of the sense of the use of their limbs. When splints are used they are removed for long periods by day so that the .patient can do what he likes with his muscles. ’The main indications for light plaster splints are to maintain abduction for deltoid paralysis in infants who
902 so much that mere tying of the arm to the bed does not suffice, and to hold the foot at a right angle. "1,’ 1 ..... -- 1.-. - - 1 - _L": elastic J<; is ew 11 er e, splints are used where necessary-e.g., the thumb can be comfortably supported in opposition with ’Elastoplast,’ when the opponens muscle is paralysed, allowing the first web space to be stretched regularly. Little is to be gained by the use of
wriggle
.....
long arm or leg splints. If one wants to hold
an
elbow at
right angles, this can be done efficiently with a collar-and-cuff, and in the legs it is enough to see that the popliteal pad prevents full extenFig. I-Wooden cross-bar incorporated in sion. We have been foot splint to prevent external rotation of lower leg. impressed with thee importance of seeing that external rotation of the leg does not produce a chronic strain of the internal lateral ligament of the knee, as may happen insidiously in a flail lower limb when the foot and leg fall outwards. As Yachnin (1947) points out, the axis of rotation at the knee is inside the midline of the joint, and the main mass of the limb outside ; the joint is more lax when its supporting muscles are paralysed, and when the lower limb falls into external rotation from the hip downwards it is the portion below the knee which rotates abnormally. This rotation strains the internal ligament and may become permanent, with severe pain and stiffness which may persist for a year or two. ’ Such a deformity is easily prevented by incorporating a wooden cross-bar in the foot splint (fig. 1). When a limb is completely flail, and careful repeated observation shows not the slightest sign of recovery, the splint is discarded and reliance placed merely on passive movements to prevent stiffness and to preserve the propriocoption which will be needed later for walking in a calliper. But such writing off must be done with caution. The deltoid muscles in particular show amazing powers of recovery, which may never take place if the small spark of power is allowed to be extinguished by overfatigue. PHYSIOTHERAPY
This is
begun
at once, with the
following provisos :
(1) in the very ill patient and in the earliest days it is probably harmful to interfere ; and (2) it must be remembered that some cases will continue to deteriorate during the first few days after admission. Patients with only mild scattered paresis on the day of admission may develop flail limbs in a few days and be in the respirator by the end of the week. Lenhard (1950) says : " Treatment for the poliomyelitis patient is commonly translated into an urge to do something.... The more that is done for the patient, the better the therapist feels. The greatest need in the early stage is rest for the patient and the muscles involved ; they do not require, nor should they have, much physical therapy."
This is true enough, but it is also true that there is an essential minimum of treatment which these patients must have. We usually begin treatment before the end of the first week, and at once in those cases where the patient has been ill at home for some days before admission and is obviously ready to recover. Only so much
attention is given as is needed to keep the joints mobile, and all joints are given a full passive range once daily. If every plane of movement is not kept in mind, unexpected contractures may develop-e.g., abduction contracture of the hip, with adductor paralysis. TREATMENT OF PAIN AND SPASM
The obstacles to daily movement are pain and spasm, not always, found in association. What is the source of this pain ?Though it is difficult to answer this question for every patient, we may
usually, though
recognise : 1. Painful spasm in the unparalysed or partly of completely paralysed muscles.
paralysed
antagonists
2. Pain due to stretching of the posterior muscles—calves, hamstrings, and erectores spinsc—which are in spasm as part of the meningeal reaction. This is not necessarily related to the onset of paralysis and is often most severe in cases which ultimately recover completely. 3. Pain arising from the joints and their ligaments, and ---4 *--""......1,.........", nnn.., ,..... r."..,.............
been relaxed
by drugs.
4. Secondary pain due to strain of ligaments from the position of paralysed limbs. 5.
over-
faulty
Perhaps pain of central origin
due to inflammation in the sensory roots and ganglia. Against this, however, is the fact that the
and
‘
patient rarely feels pain while lying perfectly still and undisturbed.
Spasm 1.
embraces:
Spasm completely
of the or
antagonists of partly paralysed
muscles.
Fig. 2-Sling-and-spring suspension from ceiling for gross paralysis of lower
2. Primary meningitic spasm of calves and hamstrings, not necessarily related to paralysis. 3. A much rarer form occurring during the progress of a limb muscle to complete paralysis. We have had only a few cases, always in the quadriceps, where the muscle, capable of little or no active contraction, feels indurated to the touch and gives the sensation of fine fibrillary contractions for 24-48 hours before it becomes soft and functionless.
However troublesome pain and mav be. thev must not be allowed to obstruct daily passive movements. Firmness on the part of the physiotherapist is essential -a single decisive movement may stretch the hamstrings where more timid attempts fail-but it may be necessary to obtain assistance from drugs. Curare in sufficient dosage will usually relieve most of the spasm and has been vigorously recommended by Dr. N. S. Ransohoff in New Jersey (Lancet 1948) ; but it does not simultaneously relieve the pain. Even when the patient has been reduced to flaccidity, movement may remain agonising, and therefore we cannot regard curare as a suitable aid to therapy, apart from its undoubted value in relieving urinary retention due to spasm of the limbs in
an
adult.
snasm
sphincters. ’
Priscol’has been reported on with enthusiasm by Smith et al. (1950) in New York, but we have not found it of great value, and its effects are less dramatic than those of curare. Intravenous procaine, in our hands, has also had only an uncertain effect on pain and spasm, even in large
dosage. The veins of small children are not always suited to the administration of these drugs, and the well-established relation between intramuscular injections and the site
903 of paralysis in closely following poliomyelitis is a. contraindication to intramuscular injections in the acute phase of the disease. We prefer not to give them except into the muscles of completely flail limbs. However, the problem of really serious pain and spasm is not a serious one in this country, where poliomyelitis seems in this respect to differ from the American variety. Thus Smith et al. found priscol valuable because it relieved the nurses of the arduous duty of renewing the hot packs in most of his cases. Not more than perhaps 10% of our cases are troubled with really severe pain and spasm, and by far the best method of obtaining full motion in such cases is under temporary analgesiaanaesthesia induced with rectal thiopentone or with gas-and-oxygen. Patients in respirators must still be taken out daily for treatment while breathing is maintained with an anaesthetic machine, and this is often just the type of case with the greatest pain. .
TREATMENT DURING RECOVERY
Once. the painful stage is over, or not too troublesome, all the children have daily massage and mobilisation for the back, where rigidity may develop even in nonparalytic cases. As recovery proceeds, passive movements give way to assisted active movements, and then to progressively more active exercises against resistance. Whenever there is gross paralysis of the lower limbs, return of power in the gluteal and adductor groups is encouraged by sling and spring suspension from eyelet hooks screwed 18 in. apart in the ceiling over the bed (fig. 2) ; in the case of young children, these can be attached to double Balkan beams slung across the cotrails (fig. 3). Patients on slings must be taught to perform single deliberate movements with a pause between each phase, or the mere recoil inertia of the apparatus will give the illusion of recovering power. The heels need be only just clear of the bed, and then the glutei maximi muscles can be exercised by forcing the feet down on the covers ; if these muscles are too weak for this, the patient is turned on his face in the slings for part of the day, so that the springs assist the movement of hyperextension at the hips. As the glutei medii recover, the apparatus can be loaded against them by incorporating a cross-spring to make abduction more difficult (fig. 2) or by weighting the slings with shot. It is important
that the exercises should not progress in activity too rapidly, but it is also important to keep slightly ahead of the patient’s capacity. The sling and springs can also be used for the shoulder if fixed to the overhead bed pulley when the patient has reached the three-pillow
stage (fig. 4).
’
INSTRUMENTATION
Future needs for surgical appliances are foreseen as far as possible, and these are ordered well in advance. We prefer to tend to over-instrumentation and then are prepared to shed part or all of the appliance when it The patient who -is becomes clear that this is safe. beginning to get up and about, whether or not with the help of a calliper, is watched more carefully, and charted
mnrn
often
+n
ensure
that trunk and hip muscles do not deteriorate under the strain. If they are evidently holding their own, he is sent home after a few weeks. When patients require tendon transplantation or foot-
stabilisation operations they are admitted to the surgical wards of this or an associated local hospital, and after operation they return to the unit in plaster. It is important to watch even apparently non-paralytic patients for a time in the follow-up clinic, because previously undiscovered weaknesses of spinal and
trunk muscles may not become obvious for some time. Since this hospital Fig. 4-Sling-and-spring susdraws its poliomyelitis cases pension from bed pulley for paralysis of shoulder largely from a geographically muscles. small but denselv populated sector of London,. many patients live within quite a short distance. We have found it an enormous advantage to be able to follow these cases through in close touch with parents and home conditions ; it is possible to train them in hospital to deal with replicas of the physical difficulties they will have to surmount at home, to prevent any overfatigue-or overprotection-in the family circle, and to watch over rehabilitation and return to work in consultation with the local resettlement authorities. Possibilities
The only reasonable outlook for the therapist in poliomyelitis is one of sober pessimism. No-one can yet cure
Fig. 3—Sling-and-spring
suspension from Balkan paralysis of lower limbs in a child.
beams
for
gross
the disease, and it has been said that the end-result after ten years is the same whatever treatment-or if no treatment-is given. While this saying may be true in so far as the sum total of potential recovery is concerned, it overlooks the fact that even this potential will not be realised if careless management allows contracture and fatigue to prevent the orderly development of what muscle power exists. It is common for a missed case not to be admitted to hospital until some weeks after the acute stage, when prompt improvement occurs in muscle groups relieved from overstrain. Would such improvement have taken place without treatment ? However pessimistic in private, we must be uniformly optimistic in encouraging the patient to make the fullest use of what he possesses, and should err in the direction of the mildest of bullying to prevent self-pity and keep his capacities fully extended. It is a mistake, for instance, to order a wheel-chair at an early stage for any young adult before he has explored to the limit his capacity to get about unaided and has found a job.
904
poliomyelitis is dominated by the rapid Mr. A. B. Taylor of the Department of Health for of irreversible changes produced by’ the Scotland) were common to all eight committees, and with the secretary (Mr. T. C. L. Nicole) they have virus in the a,nterior-horn cells of the cord. Though specific common to all antibiotics may well be discovered, there will still remain prepared the main report on " matters the problem of diagnosing poliomyelitis and exhibiting types of medical auxiliary service."1 This is followed by the reports of the eight committees. Nearly all the the antibiotic in the few hours or days before these take In the classical place. permanent changes descrip- members of these committees have approved the main tion, the paralysis of this disease is fully fledged at the report as well as their own, hut there are three outset ; but we have been greatly impressed by the minority reports expressing dissent. number of cases which enter hospital without any paraSUPPLY AND DEAIANI) at all, or only mild paresis, and then go steadily downhill during the next few days. Apart from actual In the main report a distinction is made .between death of neurones from virus toxicity, at least part of need " and " demand." By "need" is meant the the damage must be due to inflammation within the cord numbers required by the N.H.S. to give the public a, -the perivascular cuffing, oedema, and glial infiltration. full service in all parts of the country. Demand," These must be potentially reversible, and Steindler (1947) on the other hand, is defined as the number of vacancies that employing authorities are likely to seek to fill at goes so far as to postulate the essential reversibility of the lesions in the anterior-horn cells : " Up to a certain present or, say, within the next five years. Just as many different factors may limit demand, point the changes seen in these cells must be reversible, just as the inflammatory glial infiltration and the peri- many other factors may limit supply. Most entrants vascular lymphocytic exudates are reversible." to the medical auxiliary services are drawn from those This seems to offer hope for the future, now that we who pass the School Certificate or some equivalent are beginning to learn how to control the body’s response examination. From this pool come nearly all entrants to injury. It was natural to useCortisone’ and adrenoto the professions and a wide range of executives, corticotropic hormone (A.C.T.H.) in the hope of arresting secretaries, and technical staff in the public services. these disabling vascular responses to infection within the and businesses. Any gain in recruitment in one auxiliary cord, since these substances act to a considerable extent service is likely to be made at the expense of recruitment by preventing just this defence reaction in other tissues. in another auxiliary service-or in some other occupation Though a very thorough trial of A.C.T.H. by Coriell et al. which may be of national importance and already under(1950) showed no improvement whatever in paralysis manned, such as teaching or nursing. or in mortality over untreated controls and though In some of the medical auxiliary services demand cortisone produced a severe exacerbation of experimental exceeds supply, and the professional associations may infections in animals (Schwartzman 1951), it may still seek, severally and independently, to expand their ranks in order to meet it. Such competition may defeat itself, prove somehow possible to reverse the inflammation within the cord, and work should continue along these lines. and there should therefore be some means of coordinating the relation of supply to demand over the whole medical It is a great pleasure for me to acknowledge the devoted care my patients have received from Miss May Cooke, c.s.p., auxiliary field. " The problem of supply is not one of physiotherapist-in-charge, because the skill and personality meeting all requirements of all kinds as soon as possible, of the physiotherapist are far more important in poliomyelitis but of advising on a balanced programme of recruitment than anything the doctor can do. Both of us have had every over a period of time so as to try to spread the available possible help and encouragement from Dr. John Armstrong, man-power over the medical services to the physician-superintendent of Brook Hospital. best advantage." REFERENCES Though salaries were not mentioned in the terms of the report saysthat men and .women entering reference, Clarke, H. O. (1950) J. Bone Jt Surg. 32B, 631. Coriell, L. L., Siegel, A. C., Cook, C. D., Murphy, L., Stokes, J. the auxiliary services should be assured of salaries and, jun. (1950) J. Amer. med. Ass. 142, 1279. so far as possible, of prospects of promotion, similar to James, E. (1951) Lancet, i, 290. Lancet (1948) i, 254. those of occupations with comparable standards of Lenhard, R. E. (1950) J. Bone Jt Surg. 32A, 71. training. In particular " account should be taken of Schwartzman, G. (1951) New York Times, int. ed. suppl. Jan. 28, p. 7. Smith, E., Graubard, D. J., Falcone, J., Givan, T. B., Rosenthe effect of salary scales upon recruitment of both men blatt, P., Feldman, A. (1950) J. Amer. med. Ass. 144, 213. and women when the supply is below the demand.... Steindler, A. (1947) J. Bone Jt Surg. 29, 59. Yachnin, S. C. (1947) Ibid, p. 415. The outlook in
development
lysis
"
auxiliary
TRAINING
MEDICAL AUXILIARIES IN THE N.H.S. REPORTS OF THE COPE COMMITTEES
Two years ago the Minister of Health and the Secretary of State for Scotland set up eight related committees to consider the supply and demand, training, and qualifications of the following groups working in the National Health Service : Almoners
Chiropodists Dietitians Medical laboratory technicians
Occupational therapists Physiotherapists (including remedial
gymnasts)
Radiographers Speech therapists
of members agreed to accept the term " medical auxiliaries " as a designation for these groups, accepting the view that " however different their duties may be, all medical auxiliaries in the National Health Service have this in common-they work for the benefit of the patient under the direct or indirect supervision of the doctor." The chairman (Mr. V. Zachary Cope, y.R.c.s.) and two members (Dr., G. A. Clark of the Ministry of Health, and
The
majority
some of the services covered fall into groups, either because several types of auxiliaries work, together asa team under a hospital consultant or because of affinities in the work done. Thus on the one hand there is a rehabilitation group " consisting of physiotherapists, occupational therapists, and remedial gymnasts, and on the other there is a medical-social group which includes almoners with others (outside the terms - of reference) such as psychiatric social workers. Dietitians and cannot be with others. chiropodists readily grouped The committees sympathise with the view that there should be some common training in basic sciences for some auxiliaries, or at least for those in each distinguishable group ; but they note practical difficulties. For example, in certain basic sciences, such as anatomy and physiology, the same syllabus will not serve equally well for the speech therapist, the chiropodist, the radiographer, and the physiotherapist. Nevertheless the possibility of a common basic course should be kept in mind, especially when new training-schools are being "
1.
Reports of the Committees on Medical Auxiliaries, Cmd. 8188 1951. Pp. 227. 5s. H.M. Stationery Office.