338 I R I S H J O U R N A L OF M E D I C A L S C I E N C E

Oilmor, dietician, for her unfai l ing interest and attention, and Sisters Mary Arsenius and Margare t Dolores and the nursing staff for intelligent co-operation.

References 1. Armstrong, l~. D. and Tyler, F. H. (1955). J. Clin. Invest., 34, 565. 2. Blainey, J. D. and Gulliford, R. (1956). Arch. Dis. Child., 31, 452. 3. Braude, tI. (1956). S. Afr. Mad. J., 30, 83. 4. I-Iorner, F. A. and Streamer, C. W. (1956). J. Amer. Mad. Assn., 161, 1628. 5. Jervls, G. A. (1953). Proc. Soc. Exp. Biol., 82, 514. 6. Woolf, L. I. and Vulliany (1951). Arch. Dis. Child., 26, 487. 7. Woolf, L. I., Grifflths, R. and lYfoncrieff, A. (1955). Brit. Med. J., i, 57. 8. Woolf, L. I., Griffiths, R. etal. (1958). Arch. Dis. Child. 33, 167.

P O L I O M Y E L I T I C PARALYSIS OF F IFTH C R A N I A L NERVE.

CHARLES McKAY, M.D.S.,

R o y a l V i c t o r i a H o s p i t a l , B e l f a s t .

p O L I O M Y E L I T I S is an acute infectious disease caused by invasion of the central nervous system by a specific neurotropic virus, which has a predilection for the anter ior-horn cells of the spinal cord, and

for the COlTesponding motor nuclei of the brain-stem. Two types of the disease are recognised---spinal and bulbar types. I n the bulbar type, which m a y occur alone or in association with the spinal form, the brunt of the infection falls on the medulla and the pons, with involvement of the motor nuclei of the lower and, less frequently, of the, uppe r cranial nerves. I n the la t ter case there m a y be unilateral or bi lateral facia[ palsy or paralys is of the muscles supplied by the t r igeminal nerve. (Horder? 1)

Baker s divides bulbar poliomyelitis into four clinical groups, depend- ing upon the region of the medulla involved by the pathological process, as follows : (1) the cranial nerve nuclei group ; (2) the resp i ra tory centre group; (3) the circulatory centre g roup ; (4) the encephalitic group with more diffuse lesions. In the most f requent ly recognised fo rm one or more of the cranial nerve nuclei are involved. 0 n l y destruction of the 10th cranial nerve endangers the life of the patient, by producing an obstruction to the a i rway and subsequent asphyxia.

Cecil and Loeb' state that the 10th and 11th cranial nerves are most often involved, causing weakness of the soft palate, pha rynx and vocal cords, with possible resp i ra tory failure.

Paralysis of the muscles supplied by the 7th cranial nerve is of rela- t ively f requent occurrence. Many cases have been recorded by Fishbein, Salmonsen and Hektoen 8 and others. Pa tskaverova 14 discusses the clinical aspects and diagnosis of this condition.

I n a review of cases of poliomyelitis t rea ted in the Nor thern h 'e land Fever Hospi ta l in 1952, Robinson 15 stated tha t of 112 cases of acute poliomyelitis admitted, 62 were non-paralytic, 45 were paralyt ic , and 5 had polioencephalitis. Of the 45 para ly t ic cases, 12 had cranial nerve involvement, and of these the 7th nerve was affected in 7 cases, and the

P O L I O M Y E L I T I C P A R A L Y S I S O F F I F T H C R A N I A L N E R V E 339

5th ne rve in 2 cases. These last are descr ibed in the p re sen t ar t ic le . O n l y a few o the r r e fe rences to pa ra lys i s of the muscles of mas t i ca t ion have been t raced. Meads 13 men t ions a case of p e r m a n e n t closure of the j aws fo l lowing i n f a n t i l e para lys is . The cause of the closure, however , does no t a p p e a r to h a v e been pol iomyel i t i s , as the re was a lmos t comple te f ixat ion of the r i g h t t e m p o r o m a n d i b u l a r j o i n t w i th u n d e r - d e v e l o p m e n t of the mand ib le a n d dev i a t i on to the l e f t side. Th is would seem to p o i n t to an in fec t ion i n v o l v i n g the g r o w t h c e n t r e in the condyle.

Dechaume and T a r d i e u 7 record a case in which isolated a t r o p h y of the l e f t masse te r muscle was the only sequel of pol iomyel i t is , and cases of b i l a te ra l pa ra lys i s of the masse te r muscles h a v e been r e p o r t e d by H e n z m a r k 1° a n d by S i t t i g and U r b a n ) 6 Chal ier , Reve l a n d Gerest 4 re- po r t a case of fac ia l and t r i gemina l ne rve pa ra lys i s in a boy of 16 years, in whom a p rov i s iona l d iagnosis of po l iomyel i t i s was made. J akobsen ~: describes 3 cases of pa ra lys i s of the masse t e r muscles, of which 2 r e q u i r e d t r ea tmen t . Good resul t s were ob ta ined by i n t e r r u p t e d f a r a d i c c u r r e n t and massage. A r n a u d o n ~ r epo r t s a case of symmet r i ca l pa ra lys i s of the masse te r muscles in a m a n of 52 years of a g e ; t h e effects had on ly re- gressed p a r t i a l l y a f t e r 6 months . W e l t e r s ~7 r epo r t s a case of loss o f f unc t i on of the muscles of mas t i ca t ion fo l lowing pol iomyel i t i s and gives a de ta i l ed desc r ip t ion of the act ions of t he va r ious muscle g r o u p s affected and of the t h e r a p e u t i c measures unde r t aken . O t h e r cases are r eco rded by Dawe s and by Damonte , Seoane and A r r i g o 2 (The last au thors use the n o m e n c l a t u r e of " Heine-Merl in disease.") I n Dawe ' s case the p a t i e n t ' s den t i s t cons t ruc t ed a j a w suppor t . Th is caused the muscle tenderness , wh ich had been present , to d i sappear .

Three cases of weakness of t he muscles of mas t ica t ion fo l lowing acute

po l iomyel i t i s a re here r epor t ed :

CASE NO. 1 : A housewife, aged 33 years, was admitted to the Northern Ireland Fever Hospital on 27th September 1952, with a history of severe headache which had com- menced 7 days earlier, accompanied by vomiting and stiffness of the neck.

On examination, she had weakness of the deltoids and biceps, was unable to lift her head, and had almost complete paralysis of the masseter and temporalis muscles, being unable to close the mouth. She was, however, able to swallow normally. The con- dition improved gradually, and 4 days later she could eat a slice of bread, though the mouth still tended to hang open. Treatment consisted of rest and sedation, followed by physiotherapy when muscle tenderness had abated. On discharge (22nd December 1952), she had made a good recovery, though there was still slight weakness of the muscles of mastication. This persisted for more than six months after the patient left hospital, but there is now complete recovery. All teeth have been extracted and the patient wears full upper and lower dentures. She has no difficulty in chewing hard food.

CASE NO. 2 : A boy aged 4½ years was admitted to the :Northern Ireland Fever Hospital on 28th December 1952, with acute poliomyelitis affecting the right 5th cranial nerve and the left 5th, 7th, 10th, l l t h and 12th cranial nerves. There was a history of whooping-cough for 6--7 weeks before admission.

On examination, the patient had slight facial weakness and moderate meningism. He had difficulty in swallowing, and tended to choke. There was little control of the head and only clumsy movements of the hands and arms. The soft palate lifted in the mid-line and the tongue was protruded slightly to the left. On 31st December 1952, the patient was much better and could sit up and control his head. There was facial paralysis of the left side, with marked weakness of the muscles of mastication. He could swallow well.

The patient made a steady improvement, but on discharge (17th ~arch 1953), there was still left facial weakness, with diminution of the bite on that side.

Four years after discharge the masticatory muscles are still affected, though the patient's mother states that she can still see some improvement. All chewing is done on the right side. Lateral movement of the jaws is also affected to some extent. Develop- merit of the mandible appears to be normal, and the child is otherwise healthy.

CASE No. 3: A man aged 30 years was admitted to the Northern Ireland Fever

340 IRISH JOURNAL OF MEDICAL SCIENCE

Hosp i t a l o n l l t h S e p t e m b e r 1954. H e h a d c o m p l a ined o f v o m i t i n g for two d a y s , occipi ta l h e a d a c h e a n d s t i f fness o f t h e neck for one day.

O n e x a m i n a t i o n , t h e p a t i e n t was v e r y a p p r e h e n s i v e and h i s t e m p e r a t u r e was 100°F. :Neck r ig id i ty w a s p r e s e n t , b u t no o t h e r musc le w e a k n e s s , a n d no rash .

T h e fol lowing d a y t h e p a t i e n t w a s u n a b l e to swal low a n d h a d facial w e a k n e s s o n t h e r igh t side. H e h a d s o m e m e n t a l c louding. N a s a l feeding w a s u n s a t i s f a c t o r y a n d t h e p a t i e n t w a s g iven rec ta l d r ip feeds. T h e cond i t ion g r adua l l y i m p r o v e d , b u t i t was n e c e s s a r y to c o n t i n u e t h e rec ta l d r ip un t i l 5 t h October 1954, w h e n t h e p a t i e n t was able to swal low again. T h e r e w a s m a r k e d w e a k n e s s of t he facial a n d m a s t i c a t o r y musc les . T h e p a t i e n t w a s g iven g a l v a n i s m to t h e facial m u s c l e s on 5 t h l~ovember 1954, a n d d i s c h a r g e d o n 10th N o v e m b e r 1954.

W h e n s e e n a t t h e R o y a l Victor ia H o s p i t a l o n 16th D e c e m b e r 1954 t h e r e w a s sti l l m a r k e d w e a k n e s s o f t h e m u s c l e s o f m a s t i c a t i o n a n d to a less e x t e n t of t h e facial m u s c l e s , pa r t i cu la r ly o n t h e r igh t s ide , all j aw m o v e m e n t s be ing res t r i c t ed . M e a s u r e d o n a g n a t h o - d y n a m o m e t e r , a s u s e d b y Fr ie l 9, t h e b i t ing s t r e n g t h was 5 lb. on t h e r igh t s ide a n d 6 lb. o n t h e le f t s ide in t h e p r e m o l a r region. (The ave rage b i t ing s t r e n g t h m e a s u r e d on a g r o u p of 14 s t u d e n t s w a s 72 lb.)

Galvanic s t i m u l a t i o n w a s c o n t i n u e d , a n d t h e b i t ing s t r e n g t h i m p r o v e d v e r y s lowly, e.g. 5 lb. o n t h e r ighb s ide a n d 12 lb. o n t h e lef t o n 31s t D e c e m b e r 1954. O n 13th J a n u a r y 1955 i t w a s 12 lb. o n t h e r igh t a n d 18~ lb. on t h e left .

Ga lvan ic s t i m u l a t i o n was d i s c o n t i n u e d on 2 5 t h J a n u a r y 1955, a n d w h e n m e a s u r e d two d a y s l a t e r b i t ing s t r e n g t h h a d d r o p p e d to 10 lb. on t h e r i gh t a n d 12 lb. on t h e left. T h e u s e o f c h e w i n g g u m as a m u s c l e exerc i se r w a s t h e n a d v i s e d a n d t h e cond i t ion im- p r o v e d gradua l ly . One y e a r l a te r (7 th F e b r u a r y 1956), t he r e ad ings were 31 lb. on t h e r igh t a n d 45 lb. on t h e left .

Summary. Poliomyelitis is a widespre'a~t disease, but the 5th cranial nerve is only

rarely affected; no other instances have been reported in Northern Ireland in over 650 cases of the disease treated in the Northern Ireland :Fever Hospital between January, 1950, and December, 1956.

The muscle weakness can be improved considerably by (a) physio- therapy involving active and passive movements, and (b) galvanic stimulation. Improvement may continue until up to about 2 years from the onset of the disease. (Herder. 11) Cases recorded have responded to the above treatment in varying degrees. Dental advice can be of value when weakness of the muscles of mastication has been confirmed, not only on oral hygiene, but also on muscle exercises or appliances which might be of assistance in restoring muscle function.

I w i sh to e x p r e s s m y t h a n k s to Dr . F. F. K a n e , M.D., F .R .C .P . I . , Medical Super in- t e n d e n t , N o r t h e r n I r e l a n d F e v e r H o s p i t a l , for p e r m i s s ion to pub l i sh these cases , and to ]:)r. K a n e a n d Dr. F. L.LJ. R o b i n s o n for t h e i r he lp a n d advice.

References. 1. A r n a u d o n , :~[., (1949). Dtsche. Zahnarztl. Ztschr. 4, 603-605. 2. B a k e r , A. B. (1949). Papers and Disc. fnternat. Polio. Conf., 1, 241-244. 3. Cecil, 1%. L. & Loeb, R. F. (1955). Textbook of Medicine. S a u n d e r s , Ph i lade lph ia . 4. Chal ier , J . , R e v e l , L. & Geres t , F. (1941). J. de Mdd. de Lyon, 22, 485. 5. ] : )amonte , R. A., Seoane, M. M. & Arr igo, C. E. (1954). Prensa Med. Argent., pp.

3539-41. 6. ]:)awe, S. ~V[. (1951). Physical Therapy Review, 31, 12. 7. D e c h a u m e , M. & Tar i eue , A. (1931). R~v. de Stomatol, 33, 223. 8. F i s h b e i n , M., S a l m o n s e n , E. M. & H e k t o e n , L. (1951). Bibliography of i~fantile

Paralysis, 1789-1849, L ipp inco t t . 9. Friel , E. S. (1924). Trans. Brit. Soc. for the Study of Orthodontics, D e n t a l M a n u -

f ac tu r ing Co. Ltd . , London . 10. H e n z m a r k , M. H. (1932). J. Bone and Joint Surg., 14, 962. 11. ]=[order, (1952). Brit. Eneycl. Med. Practice, B u t t e r w o r t h , L o n d o n . 12. J a k o b s e n , M. (1946). Ugesk. f. Laeger, 108, 1180-1182. 13. ~ e a d s , W. E. (1904). Brit. Med. J . , i, 1425. 14. P a t s k a v e r o v a , A. G. (1953). Pedlatr. Moskva, 4, 49-54. 15. R o b i n s o n , F. L. J . (1953). Ulster Med. J., 22, 2. 16. Si t t ig , O. & U r b a n , J . (1939). Lancet, i, 865. 17. W e l t e r s , T. H. (1953). Nederl. Tydsvhr. v. (Teneesk., A m s t e r d a m , 97, 51, 3303-7.