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mal for 48 h The distribution of spinal paralysis is quite variable; rarely there may be an acute symmetrical paralysis of the muscles of the trunk and limbs as occurs in the Guillain-Barre syndrome Excessive physical activity and local injections during the period of asymptomatic infection were thought to favor the development of paralysis of the exercised muscles or injected limbs Coarse fasciculations are seen frequently as the muscles weaken; they are transient as a rule, but occasionally they persist Tendon re exes are diminished and lost as the weakness evolves and paralyzed muscles become accid Patients frequently complain of paresthesias in the affected limbs, but objective sensory loss is seldom demonstrable Retention of urine is a common occurrence during the early phase in adult patients, but it does not persist Atrophy of muscle can be detected within 3 weeks of onset of paralysis, is maximal at 12 to 15 weeks, and is permanent Bulbar paralysis is more common in young adults, but usually such patients have spinal involvement as well The most frequently involved cranial muscles are those of deglutition, re ecting involvement of the nucleus ambiguus The other great hazards of bulbar disease are disturbances of respiration and vasomotor control hiccough, shallowness and progressive slowing of respiration, cyanosis, restlessness and anxiety (air hunger), hypertension, and ultimately hypotension and circulatory collapse When these disturbances are added to paralysis of diaphragmatic and intercostal musculature, the patient s survival is threatened and the institution of respiratory assistance and intensive care becomes urgent Pathologic Changes and Clinicopathologic Correlations In fatal infections, lesions are found in the precentral (motor) gyrus of the brain (usually of insuf cient severity to cause symptoms), brainstem, and spinal cord The brunt of the disease is borne by the hypothalamus, thalamus, motor nuclei of the brainstem and surrounding reticular formation, vestibular nuclei and roof nuclei of the cerebellum, and mainly, giving the illness its name, the neurons of the anterior and intermediate gray matter of the spinal cord In these areas, nerve cells are destroyed and phagocytosed by microgliacytes (neuronophagia) A leukocytic reaction is present for only a few days, but mononuclear cells persist as perivascular accumulations for many months Nuclear or cytoplasmic inclusion bodies are not seen The earliest histopathologic changes are central chromatolysis of the nerve cells, along with an in ammatory reaction These changes correlate with a multiplication of virus in the CNS and, in the infected monkey, precede the onset of paralysis by one or several days In Bodian s experimental material, the infected motor neurons continued to function until a stage of severe chromatolysis was reached Moreover, if damage to the cell had attained only the stage of central chromatolysis, complete morphologic recovery could be expected a process that took a month or longer After this time, the degrees of paralysis and atrophy were closely correlated with the number of motor nerve cells that had been destroyed; where limbs remain atrophic and paralyzed, less than 10 percent of neurons survived in corresponding cord segments Lesions in the motor nuclei of the brainstem are associated with paralysis in corresponding muscles, but only if severe in degree The disturbances of swallowing, respiration, and vasomotor control are related to neuronal lesions in the medullary reticular formation, centered in the region of the nucleus ambiguus Atrophic, are exic paralysis of muscles of the trunk and limbs relates, of course, to destruction of neurons in the anterior and intermediate horns of the corresponding segments of the spinal cord.

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In electronics, you ll encounter various different symbols that denote the same things You might have already noticed that voltage is sometimes abbreviated by the letter E, and sometimes by the letter V In bipolar and field-effect transistor circuits, you ll sometimes come across symbols like VCE and VGS; in this book they appear as EC and EG, respectively Subscripts can be either uppercase or lowercase Remember that, although notations vary, the individual letters almost always stand for the same things A variable might be denoted in different ways, depending on the author or engineer; but it s rare for one notation to acquire multiple meanings The most common sets of abbreviations from this chapter and chapter 22 are shown in Table 23-1 Wouldn t it be great if there were complete standardization in electronics And it would be wonderful if everything were standardized in all other aspects of life, too, would it not Or would it

gray matter Stiffness and pain in the neck and back, attributed to meningeal irritation, are probably related to the mild in ammatory exudate in the meninges and to the generally mild lesions in the dorsal root ganglia and dorsal horns Probably these lesions also account for the muscle pain and paresthesias in parts that later become paralyzed Abnormalities of autonomic function are attributable to lesions of autonomic pathways in the reticular substance of the brainstem and in the lateral horn cells in the spinal cord It is of interest that poliovirus has been readily isolated from CNS tissue of fatal cases but can rarely be recovered from the CSF during clinical disease This is in contrast to the closely related Coxsackie and echo picornaviruses, which have been isolated frequently from the CSF during the neurologic illness Treatment Patients in whom acute poliomyelitis is suspected require careful observation of swallowing function, vital capacity, pulse, and blood pressure in anticipation of respiratory and circulatory complications With paralysis of limb muscles, foot boards, hand and arm splints, and knee and trochanter rolls prevent foot drop and other deformities Frequent passive movement prevents contractures and ankylosis Respiratory failure, due to paralysis of the intercostal and diaphragmatic muscles or to depression of the respiratory centers in the brainstem, calls for the use of a positive-pressure respirator and, in most patients, for a tracheostomy as well It was during the epidemics of the last midcentury that the use of Drinker s iron lung attained widespread use The management of the pulmonary and circulatory complications does not differ from their management in diseases such as myasthenia gravis and the Guillain-Barre syndrome and is best carried out in special respiratory or neurologic intensive care units The authors know of no systematic study of the potency of antiviral agents in this disease Prevention Prevention, of course, has proved to be the most signi cant aspect and one of the outstanding accomplishments of modern medicine The cultivation of poliovirus in cultures of human embryonic tissues and monkey kidney cells the achievement of Enders and associates made possible the development of effective vaccines The rst of these was the injectable Salk vaccine, containing formalin-inactivated virulent strains of the three viral serotypes This was followed by the Sabin vaccine, which consists of attenuated live virus, administered orally in two doses 8 weeks apart; boosters are required at 1 year of age and again before starting school Since 1965, the reported annual incidence rate of poliomyelitis in the United States has been less than 001 per 100,000 (compared to a rate of 24 cases per 100,000 during the years 1951 to 1955) Very rarely, poliomyelitis may follow vaccination (002 to 004 cases per million doses) The only obstacle to complete prevention of the disease is inadequate utilization of the vaccine Conceivably, with an increasing lack of immunity in underdeveloped nations, outbreaks of poliomyelitis could occur once again Prognosis Mortality from acute paralytic poliomyelitis is between 5 and 10 percent higher in the elderly and very young If the patient survives the acute stage, paralysis of respiration and deglutition usually recovers completely; in only a small fraction of such patients is chronic respirator care necessary Many patients also recover completely from muscular weakness, and the most severely paralyzed improve to some extent The return of muscle strength occurs mainly in the rst 3 to 4 months and is probably.

the result of morphologic restitution of partially damaged nerve cells Branching of axons of intact motor cells with collateral reinnervation of muscle bers of denervated motor units may also play a part Slow recovery of slight degree may then continue for a year or more, the result of hypertrophy of undamaged muscle The socalled postpolio syndrome is discussed on page 943

be isolated from the CSF and serologic tests in two patients failed to implicate any of the usual encephalitic RNA viruses, including poliovirus The patients had been immunized against the poliomyelitis viruses The tendency of West Nile virus to cause a poliomyelitis has already been mentioned

Refer to the text in this chapter if necessary A good score is at least 18 correct Answers are in the back of the book 1 The current through the channel of a JFET is directly affected by all of the following except: A Drain voltage B Transconductance C Gate voltage D Gate bias 2 In an N-channel JFET, pinchoff occurs when the gate bias is: A Slightly positive B Zero C Slightly negative D Very negative 3 The current consists mainly of holes when a JFET: A Has a P-type channel B Is forward-biased C Is zero-biased D Is reverse-biased 4 A JFET might work better than a bipolar transistor in: A A rectifier B A radio receiver C A filter D A transformer

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