may be embarrassed. If the duration of the case be long enough, symptoms of bulbar paralysis are superadded.

Progressive Muscular Atrophy. (Gowers.)

1. Wasting of the muscles of the back and arms.

2. Wasting of the trapezii and deltoids.

3. Wasting of the muscles of the neck; A, habitual posture of the head; B, position into which the head falls if it be not inclined backward.

The wasting is especially manifest in the thenar and hypothenar eminences and in the interosseous spaces; as a result, a

peculiar deformity-the claw-like hand-develops. The wasting muscles are the seat of spontaneous fibrillary contractions. Mechanical muscular irritability is heightened. The deep reflexes are enfeebled in a degree proportional to the muscular wasting. The electric reactions are also dependent upon the nutrition of the muscles and nerves. At first, they present quantitative, subsequently qualitative changes.

What are the symptoms of chronic or progressive bulbar paralysis-glosso-labio-laryngeal palsy?

The symptoms of glosso-labio-laryngeal paralysis are analogous to those of progressive muscular atrophy, the degenerative process, however, involving the nuclei of the cerebral rather than those of the spinal nerves, especially the facial, glosso-pharyngeal, pneumogastric, spinal accessory and hypoglossal. The disease is marked by difficulty in mastication, in deglutition, in respiration, in phonation and articulation, and by wasting of the muscles concerned in these functions. The affected muscles display spontaneous fibrillary contractions. Speech becomes progressively more difficult and indistinct and finally nasal. Swallowing is difficult and fluids regurgitate through the nose. Saliva dribbles from the mouth. Food may find its way into the larynx. Reflex action in the throat may be lost. Rarely the ocular and the facial muscles participate in the palsy.

How is progressive muscular atrophy to be distinguished from acute anterior poliomyelitis?

Progressive muscular atrophy is especially a disease of adult life. It is usually gradual in onset and progressive in course, while acute anterior poliomyelitis is especially a disease of childhood, and is acute in onset and retrogressive in course. Febrile symptoms attend acute poliomyelitis, but not progressive atrophy. The fibrillary twitching of the latter is not present in the former. Terminal bulbar symptoms attend progressive muscular atrophy, but not acute poliomyelitis.

Acute Bulbar Palsy.

What is acute bulbar palsy?

Symptoms almost identical with those of progressive glossolabio-laryngeal paralysis may set in acutely. They may subsequently undergo some improvement and then remain stationary. The condition is dependent upon an acute lesion—softening or hemorrhage or inflammation of the medulla, involving the nuclei of the glosso-pharyngeal, pneumogastric, spinal accessory and hypoglossal nerves or the fibers passing to or from them.

How is acute to be distinguished from chronic bulbar palsy?

The symptoms of chronic bulbar paisy are gradual in onset, progressive in course and symmetrical in distribution; those of acute bulbar palsy are sudden in onset, regressive or stationary and are apt to display slight irregularities of distribution.

Pseudo-Bulbar Palsy.

What is pseudo-bulbar palsy?

A bilateral lesion, such as softening or hemorrhage, involving the lower portion of the ascending frontal convolution of both hemispheres, or the corresponding motor tracts in symmetrical situations, will give rise to the symptoms of bulbar palsy: paralysis of the lips, tongue and throat.

How is pseudo-bulbar palsy to be distinguished from true bulbar palsy?

Pseudo-bulbar palsy, in contradistinction to true bulbar palsy, is likely to be characterized by two distinct attacks, by slight asymmetry of distribution of the symptoms, and by the absence of wasting.

Pseudo-Hypertrophic Paralysis.

What are the symptoms of pseudo-hypertrophic paralysis? Pseudo-hypertrophic paralysis is a congenital family-affection, transmitted through females but occurring more commonly in

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males, usually appearing in childhood, and characterized by weakness and enlarged muscles, the fibers of which undergo atrophy, while the interstitial tissue increases. The muscles of the calves and the infra-spinati usually participate in the en

Pseudo-hypertrophic paralysis in two brothers. (Gowers.)

largement in striking degree. Wasting of the latissimus dorsi and of the lower portion of the pectoralis major is characteristic.

The gait has a peculiar oscillating character; ascending stairs is difficult, and the manner of rising from the floor is characteristic (Fig. 47): the patient first gets on his hands and knees; then extending the legs he stands upon his feet; finally, by supporting his hands upon his thighs he manages to reach the erect posture. Ultimately the muscles become reduced in size; the electric reactions suffer quantitative changes, indica

Pseudo-hypertrophic paralysis. Mode of rising from the ground. (Gowers.) tive of diminished excitability; the deep reflexes are enfeebled and lost. Talipes equinus, spinal curvature and muscular contractions occur at a late stage of the disease.

Simple Idiopathic Muscular Atrophy.

What is simple idiopathic muscular atrophy?

There is a condition, allied to pseudo-hypertrophic paralysis, in which the muscles atrophy, but do not become enlarged by interstitial deposit. The affection occurs in families, is as common in females as in males, and usually appears in early adult life.

What are the symptoms of simple idiopathic muscular atrophy?

Simple idiopathic muscular atrophy sets in gradually, with weakness and wasting in the face, arms or legs and extension to the rest of the body. The deep reflexes become enfeebled, deformities result and the electric reactions are quantitatively changed. Among other muscles, the latissimus dorsi, the