Dr. F. A. Kleinhans, Milwaukee, Wis., said that he has Dr. L. Duncan Bulkley, New York City, said that he has been a sufferer from psoriasis for 18 years, and has tried prac- used carbolic acid in psoriasis, and knows what it will do in tically everything in the line of treatment both internal and certain cases. He thinks it entirely erroneous to regard psoria- external, the ay-rays alone excepted. He is firmly convinced sis as incurable. He also disagrees with those who claim that that psoriasis is not of parasitic or microbic origin, but is a it is impossible to get patients to live on a vegetable diet. cutaneous manifestation, due to faulty metabolism, in fact a He had one psoriatic patient who has been a vegetarian for sort of autointoxication. In sections of most recent psoriatic 10 years, and a number who have abstained from animal food lesions excised from his own person, he has found a para- for from 3 to 4 years. He has seen psoriatic outbreaks follow- keratosis, i. e., a thickening of the horny layer and dilatation ing a shock or mental strain. In the treatment of psoriasis, of the vessels of the eorium and round cell infiltration sur- patients should be kept under observation for a long time rounding the dilated vessels and the sweat coils. Among after the eruption itself has actually disappeared. The same other methods he has tried the hypodermic use of arsenic (as thing is done in syphilis and in gout. Psoriasis can be cured Fowler's solution) and found it very painful. At times he in a certain proportion of cases. Those not cured are the ones can rid himself very readily of the lesions in the course of in whom the basic cause of the eruption can not be discovered. a week or two by taking 5 grains of bicarbonate of potash 3 times daily; at other times this remedy has no effect. Sometimes Fowler's solution proves beneficial and again it fails, or even aggravates the condition. Thyroid extract has UNILATERAL ASCENDING PARALYSIS AND also been tried without effect. He believes that there is any DESCENDING PARALYSIS. no one remedy that can be depended on in all cases at all UNILATERAL time«. THEIR CLINICAL VARIETIES AND THEIR PATHOLOGIC Dr. L. said has William Baum, Chicago, he always regarded CAUSES. psoriasis as a dermato-neurosis. In the first place, there is a distinct hereditary tendency to the disease, as it can be CHARLES. K. MILLS, M.D. traced from generation to generation, following practically the Professor of Neurology in the University of Pennsylvania; Neurol- same type as does a psychosis. The mere fact that so many ogist to the Philadelphia General Hospital; Consultant to remedies have been recommended by different authorities in- the Philadelphia Orthopedic Hospital and Infirmary dicates that the opportune moment effected the cure rather for Nervous Diseases. than the remedy. He has frequently observed exacerbations PHILADELPHIA. violent emotional disturbances. The of the disease after erup- a to Phil- under In December, 1899, I presented paper the tion may disappear rapidly when the patient is placed in which I called atten- a different environment. This does not depend so much on the adelphia Neurological Society a I as uni- as the disease is observed in both warm and cold tion to new clinical type which designated climate, sim- climates. In the majority of cases, the patients should be lateral progressive ascending paralysis.1 Somewhat made to understand clearly that the disease is incurable, ilar cases have since been described under such terms as although in some instances it is limited to a single outbreak. progressively developing hemiplegia, chronic progressive Vaccination and injections of antitoxin may be exciting factors hemiplegia, and ascending unilateral paralysis. Uni- in causing an outbreak. In Cook County Hospital, Chicago, lateral ascending paralysis is probably the simplest and, about 3,200 patients have been given injections of antitoxin therefore, the best designation for the symptom-complex. and a decided number of the injected have returned patients Since of the first contributions on this with psoriatic efflorescences attributed to the antitoxin. Still, the publication has attracted some atten- any other form of irritation mig1!' have the same effect. In type of paralysis, the subject as war- over 70 per cent, of the patients who returned, Dr. Baum was tion, but not perhaps as much its importance able to get a history of psoriasis either in the parents or rants. Probably not a few cases of progressively ascend- collateral branch of In grandparents, or in some the family. or hemiparesis have failed of record be- the treatment of the of neurotic ing hemiplegia psoriasis, possibility origin cause of the slowness of of the affection and should be remembered. development always the overlooking of the essential feature of upward pro- Dr. David Lieberthal, Chicago, said that all are agreed as Some cases no been to the difficulties connected with the management of psoriasis. gression. have, doubt, passed by as or as of focal It is difficult to have a patient carry out such strict diet as lacking in interest, probable instances Dr. Bulkley demands. Dr. Lieberthal has under his care a disease not worthy of elaborate report. patient with psoriasis who years ago was treated by Dr. Bulk- Practical medicine is advanced by directing attention the disease the treatment ley and freed from through diet to clinical or entities which are in their But remarked that he would rather types peculiar exclusively. the patient method of their or their keep his skin affection than undergo such a diet treatment development, symptomatology causes. One which has been again. It can not be denied, however, that regulating the pathologic point brought diet of certain patients with systemic derangements will bring out during the brief history of the existence of progres- about good results. Dr. Lieberthal has under his care a sively ascending hemiplegia is that unilaterality and patient who for 16 years was not relieved of his affection upward progression of the paralysis are exhibited by in spite of having had the benefit of the best dermatologie affections in their care here and abroad. The patient's urine was loaded with differing pathology. unilateral as- urates and uric acid and after his diet was accordingly modi- A close study of the recorded cases of fied, the skin cleared up and remained so until his death, 18 cending paralysis shows that this clinical type in a more months later. It is important to see the patients at short or less pure form may occur, 1, as the result of primary intervals in order to observe the lesions and to control the of the tracts to which may be internal administration of External treatment should degeneration pyramidal drugs. added other lesions; 2, as the stage be employed with due diligence and if chrysarobin is degenerative early applied, sclerosis as the form assumed uni- it should not be allowed to spread to the normal skin, other- of disseminated ; 3, by wise it is apt to produce a dermatitis, on the basis of which lateral amyotrophic sclerosis; 4, as the order of progres- new psoriatic lesions may develop. Arsenic should be ad- sion in unilateral paralysis agitans; 5, as the expression ministered rather in older cases of limited area. If Fowler's a should be the solution is used fresh preparation secured as Read in the Section on Nervous and Mental Diseases of the older becomes inert. Dr. Lieberthal said that he uses the American Medical Association, at the Fifty-seventh Annual Session, but in the severe inveterate cases. June, 1906. œ-ray in psoriasis, only the of last From the Department of Neurology of University Any treatment employed should be carried out until the Pennsylvania. traces of the disease have disappeared. 1. Jour. Nerv. and Men. Dis., April, 1900.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 before of a focal lesion either cerebral or 6, as a clin- Case 1.—A man, aged 52, about two years coming spinal; under to of weakness in the ical in and as a observation,1 began show signs right type cerebrospinal syphilis; peripheral lower Weakness in the arm or a affection. extremity. appeared eighteen hysterical months after the impairment in the lower extremity was first In my description of the first case (rather of the first noticed. This soon became more and more evident, and was two cases of unilateral ascending paralysis, for brief ac- accompanied by the tendency to carry the arm raised against count was given of a second case seen many years before the body and flexed at the elbow. the publication of the paper), I suggested that the dis- When first examined the paresis in the upper extremity, ease probably represented a new clinical type due to although easily determined, had not nearly reached the de- slowly increasing degeneration of the pyramidal fasci- gree of impairment observed in the leg. The right side of the face was also was distinct in the culi or of the cerebral motor neuron systems. slightly paretic. Wasting lower the measurements showing a difference The cases which have been recorded others as well right extremity, by of one and a half inches for the thighs and five-eighths of an me to as by myself, since attention was first called by the inch for the calves. The various movements of the right leg of cases clinical type ascending hemiplegia, even those were distinctly weaker than those of the left, but were nowhere which have been regarded as instances of pyramidal de- absolutely abolished; similarly all the movements of the right generation, have varied somewhat in their clinical fea- arm were distinctly impaired. Faradio contractility was re- tures. In some, for has been present tained. The affected limbs were not spastic nor contracted. example, spasticity of from an early period ; in others it has been absent or has Careful examination showed retention of all forms sensation. tendon and muscle on the side were all been but slightly marked. The reflexes, exagger- The phenomena right usually somewhat was plus on the left side, have in one or two instances been diminished or exaggerated. Knee-jerk ated, but more on the Patellar marked the but considerably exaggerated right. only moderately ; wasting usually present clonus and ankle clonus were present on the right, but amount slight moderate has varied in in different cases. As the not on the left. The plantar reflex was normal on the left; but literature of this affection is still meager, I shall take on the right, while the Babinski response was not present, occasion to give a résumé of all the cases so far published, downward flexion of the toes was distinctly less marked than unless, indeed, some reported case has escaped my inves- on the left. tigations. Case 2.—A woman, aged 43, first noticed weakness in her Before I desire to direct attention left leg while pregnant with her last child, three years before doing this, however, under observation.1 A few months later the left arm to unilateral which is to be re- coming descending paralysis, became paretic. The reflexes were much increased on the af- as the same reversed. Unilateral as- garded simply type fected side. The patient remained under observation for many cending paralysis due to degeneration of the pyramidal months, the paresis of the leg and arm slowly increasing. or to tracts, this and some added condition of degen- Neither leg nor arm was contractured, and sensibility was pre- eration, is the more common form of progressively de- served. The patient complained at times of pains in the limbs veloping hemiplegia, but an affection essentially the and twitching in the leg and arm. same sometimes takes a reversed order so far as the This woman was under my care more than 20 years ago and limbs or as the face and limbs are concerned, giving us had previously been a patient of the late Dr. E. C. Seguin, who a lesion a unilateral descending paralvsis or a progressively de- believed that there was cerebral causing secondary the of two of changes in the crossed pyramidal fasiculus. The view taken scending hemiplegia. Through courtesy was in the tracts were of in Dr. David by me that the alterations pyramidal my professional colleagues Philadelphia, the nature of a lateral but were and not sec- Riesman and I sclerosis, primary Dr. William Pickett, shall have the to cerebral lesion. I have learned that the patient to in ondary any opportunity present the concluding portion of this was alive about fifteen years after she was first seen by me and paper two cases of this descending type, the one an ex- had become entirely unable to walk. Just how she was affected ample of disseminated sclerosis taking at first the uni- at this time was not ascertained, except that she had become lateral descending and systemic form, and the other triplegic, the affection having evidently passed over to the lower probably an instance of nearly pure pyramidal degener- extremity on the side opposite to that on which it had started. ation. Case 3.—A man, aged 41, four years before coming under the notice of the reporter,' began to have a sense of weakness That the of a new clinical is some- suggestion type in the left lower limb in walking. This weakness in- times fruitful in the of is illus- gradually development diagnosis creased, and in about a year the left upper limb also to trated the brief of began by history progressively developing be weak. The patient was positive that a year had elapsed hemiplegia. The report of two or three cases of uni- after the impairment in power in the lower limb before he felt lateral ascending paralysis of unusual form has called any weakness in the left upper extremity. He had never had attention to the question of ascending and descending any symptoms of an apoplectic seizure. unilateral types of certain well-known diseases, such as This showed that the movements of the left lower disseminated sclerosis, paralysis agitans and amyotro- limb were very spastic, but not in the least ataxic. The phic lateral sclerosis. Variations in the symptomatology toes of the left foot scraped the ground, and this foot was in- verted in The left knee-jerk was much more marked of these reported cases have also awakened interest as to walking. than the right, which was, however, prompt. Ankle clonus and the probably differing pathology of some of the cases recorded. the Babinski response were present on the left, but not on the right. Sensation was normal. The left limb was weaker After upper summarizing in the briefest manner possible than the right; it was also spastic, but the weakness and the cases of unilateral ascending paralysis hitherto pub- spasticity were less than in the lower extremity. The left upper lished, and after some discussion of the different forms limb was held slightly flexed at the elbow and against the body, but no contractures were of disease of the nervous system which may present a present anywhere. Speech was nor- but mouth could not be drawn well the progressively developing hemiplegia, ascending or de- mal, the up as on left side as on the The went to the left on scending, I shall record one new case of unilateral as- right. tongue slightly protrusion. Ophthalmoscopic examination showed white cending paralysis and one new case of unilateral de- atrophy of the left optic nerve. Wasting which was present also the case referred to scending paralysis, describing was like that occurring in hemiplegia. me Dr. when the by Riesman, considering unilateral as- Case 4.—A youth, aged 19, about four years before coming cending and the unilateral descending types of dissemin- ated sclerosis. 2. Spiller, William G.: Philadelphia Med. Jour., Feb. 9, 1901.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 under observation3 began to drag his right foot; it tended to tions, movements of the ocular muscles and the fundus oculi cross in.front of the left, and he wore off the sole of his right were all normal. The sphincters were also normal and the pa- shoe at the toe. Two years later he had diplopia, which lasted tient was mentally sound. The reporter gives in careful detail for five months. The right leg at this time was somewhat a description of the musculature and of the movements per- smaller than the left. About three and a half years after the formed or incapable of proper performance on the right half right foot first began to drag, which was about five months of the body. Summarized, this indicated marked loss of power before coming under observation, weakness was noticed in the and atrophy in both the right upper and lower extremities, con- right arm. siderably greater in their distal than in their proximal por- Examination showed that when the patient walked the tions. The affected limbs were neither spastic nor ataxic, but right leg was rigid and the toe dragged. The movements of gave rather the appearance of flaccidity or flabbiness. The the right leg could be performed, but were distinctly weaker paralysis and atrophy were not localized to special groups of than those of the left. The right leg and arm were both some- muscles. Marked quantitative change to the faradic current what atrophied. The adductor pollicis muscle of the right hand was present, being especially noticeable in the muscles which was not so large or firm as that of the left. The muscles every- showed the greatest wasting, these being the hand muscles, where responded to the faradic current; the tendon reflexes the anterior tibial and the peroneal. All the deep reflexes were on the right were all exaggerated, and a well marked Babinski greatly exaggerated on the right side. The Babinski extensor reflex was present on this side. The reflexes on the left, while response was typically present, but there was only an indication of ankle marked, were much less active than those on the right. Plantar clonus. Some paresis of the muscles supplied by the stimulation caused slight extension of the great toe and flexion seventh nerve and marked loss of power in the motor distribu- tion of the fifth of the others. Right-sided facial paresis was present. The nerve were present. muscles of the right side of the throat were also paretic, and Case 7.—A woman, aged 50, was seen in consultation in Oc- the voice had a distinct nasal twang. Nystagmus and paresis tober, 1905." In August, 1904, she first discovered some weak- of the left inferior reetus, and pallor of the temporal halves ness of the right lower extremity, although it may have been of the discs were other symptoms. All forms of sensibility present in mild degree before. The weakness and awkwardness were everywhere preserved. The patient showed a slight Rom- in using the limb very gradually increased until about one or berg symptom, and at times while standing or walking, a ten- two months before coming under observation, since which time " dency to lose his balance. The case was regarded as one of dis- the impairment had increased more rapidly. The patient had seminated sclerosis, beginning as unilateral ascending paralysis. suffered no pain in the extremity, in the back or in the head, Case 5.—A man, aged 60 at the time of his death, about and had no symptoms of cerebral disease. She had occasional eight years before had some paralysis of the right extremities.* headaches which seemed to be of the migraine type, and now At this time knee-jerk and biceps-jerk were increased on the and then had a slight vertigo, but this was probably due either affected side. Four years before his death hospital notes showed to the condition of her stomach or to some arteriosclerosis. some loss of power in both the right leg and right arm; and all Examination of the right lower extremity showed gen- the muscle and tendon phenomena on the right side were exag- eral paresis of moderate degree in the entire limb; that is, gerated, patellar clonus and ankle clonus both being present; all movements were impaired in force without definite lo- also the speech was slightly affected, and sensory impairment calized palsy of any group of muscles. The movements of and astereognosis were absent. flexion, extension, abduction and adduction of the foot and also Notes made between two and three weeks before death showed intermediate movements were distinctly impaired as compared that he was markedly paralyzed in the right leg, and to a less with those of the left foot, but the reduction in power extended extent in the right arm ; also that he was paralyzed in the to the entire limb, although it appeared to be more marked left leg, but not as seriously as the right. The paralyzed distally. The right knee-jerk was greatly exaggerated and limbs were spastic, and the tendon and muscle phenomena were patellar clonus could be elicited. Persistent ankle clonus and all exaggerated. He had ankle clonus on both sides, and patel- also a decided Babinski response were present on the right. lar clonus and the Babinski response on the right. Sensory Front tap was present and marked on the same side and the phenomena were absent. The face was not paralyzed. Con- muscle jerks were also plus on this side. On the left the knee- tractures and wasting were absent. During two or three years jerk was somewhat above the usual norm, as were also the before his death he was treated for cardiovascular symptoms, muscle jerks, but patellar clonus and front tap were absent. including attacks of angina. The plantar response on this side was irregular. Careful ex- Postmortem showed advanced disease of the heart, vessels amination was made for sensory disorders, with absolutely neg- and kidneys, the case being an extreme instance of arterio- ative results. Examinations seemed to show some slight im- sclerosis. Chronic pleurisy and tuberculosis with cavity for- pairment of the upper extremity, but so slight that it was mations were present. Microscopic examination showed in- hardly fair to record it as present. tense and long standing degeneration of the right crossed Case 8.—A young man, aged 23, complained that for six and left direct pyramidal tracts, the degeneration extend- months his left leg had been growing gradually weaker. He ing into the pons, but not into the left cerebral peduncle; would sometimes trip because he could not clear the ground also comparatively recent degeneration of the left crossed and well with the tip of his left foot. At times also he could not the right direct pyramidal tracts, traced by the method of use the left arm well. His condition for about one year is de- Marchi into the lower part of the right internal capsule. No scribed by the reporter.' lesions, degenerative or focal, were found elsewhere in the brain His walk suggested a foot drop on the left side, but did not or spinal cord. show the circumduction frequently exhibited by hémiplégies. Case 6.—A young woman, aged 18 at the time of first com- Dorsal flexion of the foot was very feeble, movements of the ing under observation,5 was noticed to show slight clumsiness toes being almost completely lost. Movements at the left knee and awkwardness in using the right hand and foot shortly and hip could all be performed, but with less force than on the before the age of fourteen. Gradually the weakness of the right right. Knee-jerks and heel-jerks were lively on both sides, lower and upper extremities increased, this from description but much more marked on the left than on the right, and after being more marked proportionately in the former than in the three or four months ankle clonus could be elicited. The Ba- latter. When between seventeen and a half and eighteen years binski response was absent on both sides. The entire left lower old a slight swelling of the right half of the thyroid was noticed. extremity was not spastic but flaccid and the seat of general was smaller Examination showed no abnormality of cutaneous and wasting. The left upper extremity than the right. was also shown in the neck and shoulder. muscular sensibility nor of the special senses. Pupillary reac- Atrophy distinctly As time progressed the left upper extremity became completely The left face showed no or 3. Potts, Charles S.: Jour. Nerv. and Ment. Dis., xxxviii, No. 10, paralyzed. paralysis atrophy. October, 1901. 4. Mills, Charles K., and Spiller, William G.: Jour. Nerv. and 6. Mills, Charles K.: Jour. Nerv. and Ment. Dis., xxxiii, No. 2, Ment. Dis., July, 1903. February, 1906. 5. Patrick, Hugh T.: Jour. Nerv. and Ment. Dis., xxx, August, 7. Newmark, L.: Jour. Nerv. and Ment. Dis., xxxiii, No. 3, 1903. March, 1906.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 Examinations made several years after the first observation for touch and pain was normal in the extremities and in the of the patient gave, by the Oppenheim method, a flexor response face. Speech was normal. in the smaller toes of the right foot, and a distinct extensor Eye examination revealed extensive chorioretinitis with well response in the big toe of the left foot. The response to both advanced optic nerve atrophy. The pupils responded sluggishly the faradic and galvanic currents was normal. All forms of to light and more promptly to convergence. No diplopia or sensibility, the special senses, and the bladder and bowels were muscle insufficiency was present. The fields were much con- normal. Absence of exaggeration of the deep reflexes in both tracted, especially on the temporal side. Patient passed from upper extremities was an incongruous feature of the case. under observation before an entirely satisfactory investiga- of These cases represent the literature of this subject as tion his case was made. known to me up to the time of the preparation of this PARALYSIS. paper. They all seem to present in their symptomatol- UNILATERAL DESCENDING ogy evidences of the probable degeneration of the pyra- I had the opportunity of seeing and studying the fol- recur to midal tracts, crossed and direct. I shall again lowing interesting case through the courtesy of Dr. Case 1, when discussing the subject of the unilateral as- William C. Pickett, of Philadelphia, whom I had re- of case was cending type paralysis agitans, which this be- quested, with others, to be on the lookout for cases of lieved to be by Patrick. Whatever the case was in its unilateral ascending and unilateral descending paralysis. features a totality, it certainly presented some of the of Dr. Pickett, on first seeing the case, at once recognized case of pyramidal degeneration. Case 2, seen by me that it belonged to the type of progressively developing more in' than 20 years ago, and, therefore, reality, the hemiplegia, in this case taking a descending course. one first case observed, was without doubt of progres- Case 10.—A about had been well until three to woman, 45, years sively ascending hemiplegia due pyramidal degenera- before coming under observation, when for the first time she 7 8 to to tion. Cases 3, 5, 6, and seem belong the type noticed a weakness in the left arm on attempting to use it. first indicated by me, although differing in some fea- She soon lost the power of lifting and projecting the arm. The tures, especially as regards spasticity, the reflexes and impairment of power became more marked in the distal than wasting. The solution of these differences can only be in the proximal portion of the limb, and a few months after the the of hand at the had as we gain more knowledge by the study of cases, the onset of paresis movements the wrist and those of the became much impaired. and especially as we acquire additional pathologic data. fingers About one from the when the arm was first affected Case that of a observed in year time 5, patient originally my In wards at the General and she noticed some weakness in the left leg. describing the Philadelphia Hospital, pub- condition of her lower extremity at this time she said that she lished me in with Dr. is the by conjunction Spiller, only felt as if she made miscalculations in stepping up or down. one as in yet which necropsy and microscopic examin- In walking, the toes and fore part of the foot would catch or ation have shown degeneration limited or almost limited not be lifted properly, causing her to stumble. She soon had a to the crossed and direct pyramidal tracts. Case 4, re- limping or dragging gait. In the course of five or six months corded by Potts, was, in all probability, as he suggests, a marked degree of paralysis developed in the left lower extrem- one taking the form of unilateral ascending paralysis in ity. The left upper and lower extremities had been in a condi- a of disseminated sclerosis. tion of gradually increasing helplessness during the last 18 comparatively early stage months. The said that she felt as if she had to This case will be presently referred to again when con- patient carry the unilateral of disseminated them with the other part of the body. She had also a curious sidering ascending type feeling of loss of power in the abdomen or bowels of the left sclerosis. side. Her face and ocular muscles had not been affected. I next an case shall present the details of unrecorded Neither before nor since the on of the the which not coming paralysis of unilateral ascending paralysis—one does patient had not had any severe headache, paroxysmal or con- seem to belong clearly with any one of the 8 cases just tinuous, or any spells of nausea, vertigo or vomiting. She had summarized. It is apparently an illustration of cerebro- also had, so far as she knew, no disorder of sight, hearing, spinal syphilis, taking the unilateral ascending form. smell or taste. She had had no loss of control or other affection of the bladder. She had had no douole vision or no in Case 9.—The patient, a man, aged 55, had no family history difficulty of importance. He had worked in lead 10 years before coming dragging in the affected limbs. Her menses had continued reg- under observation. Four years before this time his right leg ular, and her bowels had also been regular with the exception occasional began to grow weak, the impairment of power steadily in- of constipation. creasing. The veins of the right leg were markedly varicose. Careful examination gave the following results: Left A dull aching pain developed in the heel and in the calf in arm was limp or flaccid, the only place where any con- the region of the varicose veins. The aching had grown worse tractures were shown was in the fingers, which were half with the weakness. Three years after the onset he first be- flexed at the first and second phalangeal joints, but this condi- gan to notice weakness and aching in the right arm, these in- tion of contracture was a passive rather than an active one. creasing steadily. Shortly after this weakness became notice- The bend of the fingers was evidently due rather to loss of able in the left knee and ankle, with some ache in the heel. power in the extensors than to any active spastic condition of The left arm remained normal. The bladder and bowels were the flexors. The fingers and thumb dropped into the hand. not involved. He occasionally suffered from backache. The loss of power in the limb was greater distally than proxi- Examination showed that in walking the patient dragged mally. She could elevate the entire extremity to an angle of his right leg. Power in the right leg was greatly di- only about 45 to 50 degrees with the shoulder. She could, minished but normal in the left. The right arm was weaker however, bend the forearm about half way, and extend the arm than the left. The right lower face was paretic. He could not against resistance, but with about half the normal power; in draw the right angle of the mouth up; on smiling the left angle other words, the movements of the upper arm were considerably of the mouth was drawn upward more than the right. He could impaired but all retained. She could not pronate or supínate, wink each eye separately, the left better than the right. Pa- the forearm; she could not flex the hand on the wrists; she tient stated that his left arm and leg were beginning to feel could not ulnar flex it or fully extend it, but had some power as the right extremities felt a year or more before. Muscular of extension, especially showing itself toward the radial side of the hand. She could extend atrophy was absent. Standing with his eyes shut he almost not the fingers at the metacar- fell. Both knee-jerks were exaggerated, the right more than pophalangeal articulations or distally. She had some slight the left. The ankle-jerk was exaggerated on the right but flexor power in the movements of the fingers. She could adduct diminished on the left. The Babinski response was obtained and abduct the thumb which lay helpless toward the palm. In- showed some the on the right, but not on the left. Biceps and triceps reflexes spection apparent slight wasting of supra- muscles and of the were increased on the right and normal on the left. Sensation scapular perhaps small muscles of the hand.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 There was not, however, the distinct atrophy which is so marked duced by long examination. This ocular examination is im- in amyotrophic lateral sclerosis and progressive muscular portant as indicating the absence of a focal lesion like a cerebral atrophy of the Aran Duchenne type. tumor. Measurements of the Uppeb Extremities. This interesting case, which I examined with great Middle of left forearm..7% in. Middle of right forearm..7% in. care, is an excellent illustration of a progressively de- Left hand .7 In. Right hand .7% in. veloping descending hemiplegia in all probability due She dragged the left leg in walking, but not with the cir- to primary degeneration of the tracts, with of foot which shown so pyramidal cumduction movement the is in many possibly some slight involvement of other parts of the cases of hemiplegia. The lower extremity, like the upper, was neuraxis. With the of the but not in any as exception slight hypesthesia partially paralyzed, part quite markedly on the affected case was The loss of was side, the purely motor, and had affected as the upper extremity. power more the usual marked distally than proximally. The movements of the left diagnostic concomitants of a purely motor foot were tested and compared with those of the right, and all case, namely, abnormal increase of the deep and super- were found greatly impaired but none completely lost. Those ficial reflexes. The hypesthesia, like the sensation of most affected were dorsal flexion of the foot and dorsal flexion dragging of the limbs, seemed to be due to suggestion. with adduction. The arch of the foot was somewhat flattened; The case in this respect reminded me of the idea long the foot showed a tendency to turn outwards, exhibiting a since advocated by Charcot, that the slight or moderate The movements of the on the of partial valgus. leg thigh, impairment of sensation sometimes observed in cases the on the and all other movements of.the thigh pelvis thigh due to a motor cerebral lesion was could be performed with considerable force, but less energet- apparently strictly sometimes best on the of ically than the corresponding movements on the right side. explained hypothesis hysteria or to The muscles of both the lower and upper extremities responded suggestion. It undoubtedly belongs the clinical everywhere to the faradic current, but with some quantitative group of unilateral descending paralysis, the pathology diminution, particularly in the upper limb. being the same as that which is present in at least some cases of unilateral the Measurements of the Lower Extremities. ascending paralysis, degenerative Middle of left leg.11% In. Middle of right leg_12% in. lesion, however, having developed in the upper part of Left foot . 7% In. Right foot . 7% in. the spinal cord and later in the lower. It is unlike the The two sides of the face were symmetrical. She had about cases presently to be described, the one referred to me by equal control over the movements of the left and of the right Dr. Riesman, in which some of the symptoms seemed side of the face. The tongue was protruded straight and to point unerringly to a disseminated sclerosis beginning showed no fibrillary tremor. No loss of power was present in as a descending hemiplegia. The descending types of the masseter, temporal and pterygoid muscles. Ocular move- amyotrophic lateral sclerosis and of unilateral paralysis ments were normal; there was no nystagmus. Articulation, agitans could be easily excluded, the former chiefly by enunciation, phonation and swallowing were normally per- the true The of the and head and the facial absence of spasticity, decided wasting, fibrillary formed. pose body expres- and the latter sion had none of the seen in paralysis agitans. tremors, partial degeneration reactions; appearances face and fixed Knee-jerk and quadriceps jerk were much exaggerated on the by the absence of tremor, masked pose disease. left ; they were present but not increased on the right. Patellar and all the truly typical features of Parkinson's clonus was absent on both sides, as was also ankle clonus, al- Nystagmus, disorders of speech and other symptoms and though a slight tendency to clonus was twice shown on the left. signs of disseminated sclerosis were absent. The case Achilles jerk was marked on each side. A typical Babinski was inexplicable on the theory of a focal lesion ; syphilis, reflex was present on the left, the great toe extending distinctly hysterical paralysis and peripheral disease could all be and somewhat deliberately, the other toes more quickly but excluded. less decidedly. On the right the small toes were plantar flexed on stimulation of the sole, the great toe sometimes extended UNILATERAL ASCENDING TYPE OF DISSEMINATED and sometimes flexed, but when it extended it was not in the SCLEROSIS. same typical and deliberate manner as on the other side. Exam- first show itself as a ination of the upper extremities was made for the wrist, and Disseminated sclerosis may spas- one lower elbow jerks and the von Bechterew reflex and its modifications. tic paralysis which, beginning in the extrem- The jerks were a little more marked on the left than on the ity, ascends in a greater or less time to the upper. It right; the most marked responses were the triceps and the can not be doubted that Case 4, reported by Potts, is one infra-spinatus which, while not greatly exaggerated, were un- of this kind, as in addition to unilaterality and progres- doubtedly more marked on the left than on the right side. sive ascent, this showed several of the typical and was patient Well marked anesthesia to touch, pain temperature of disseminated as of nowhere and examinations showed signs sclerosis, nystagmus, pallor present, but careful repeated the halves of the discs and some incoordin- on most of the left half of the body like that temporal slight hypesthesia ation in and In cases of this so often seen in hysteria and hystero-neurasthenia of traumatic standing walking. descrip- tion it is that the sclerosis at first origin. Her answers, however, were not uniform as to the lim- altogether probable itations of this slight hypesthesia. Above the waist, for in- largely attacks the pyramidal tracts and assumes an al- stance, her replies seemed to show that the sensation was fully most systemic form. This tendency, to a large degree retained nearly all over the region of the left scapula and of of systematization, is sometimes observed in cases of the deltoid. bilaterally beginning and progressively increasing dis- Dr. G. E. deSchweinitz made the following report: seminated sclerosis. left 6.5 Vision, right eye 6/5; eye, 6/5. A., right eye, D; A case of the form of disseminated sclero- left 6.5 D. normal in all their hémiplégie eye, Pupils reactions; sis recorded Thomas and differs from the case in size. No no limitation of rotations by Long8 equal diplopia; of Potts in that the were not motor. of exterior ocular muscles. Esophoria less than one degree. symptoms purely seven before death be- discs of color; retinal circulation normal in dis- Case 11.—A man, aged 47, years his Optic good the of increas- tribution and carrying normally tinted blood; slight enlarge- came paretic in his right leg, impairment power and added to it diminution of and incon- ment of retinal veins, but no decided disproportion between ing having sensibility urine and feces. in the size of veins and arteries. No ophthalmoscopic changes in the tinence of Some improvement symptoms his but two before his death these retina or choroid. Dr. deSchweinitz remarks that the ocular in right leg occurred, years increased and numbness and paralysis in the right examination is practically negative; that the eyes are normal; gradually that a of the color fields found to be slight contraction present 8. Thomas, A., and Long, E.: Compt. rend. hebd. des Seances is probably due to lack of concentration from retinal tire in- de la Soc. de Biol., Oct. 13, 1899, No. 28.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 arm appeared. The year before his death he had almost com- right-sided suprascapular atrophy; nystagmus; increased right plete paralysis in the right lower extremity with contractures, knee-jerk with slight ankle clonus; normal reaction of pupils exaggerated deep reflexes on the affected side, including ankle to light and distance ; and intact sensation. Later notes made clonus; also slight atrophy of the lower extremity. The right by Dr. Riesman showed that the left pupil was larger than the upper extremity was a little paretic, the reflexes at the wrist right; also that the pupils reacted sluggishly both to light and and elbow were exaggerated in both upper extremities, but accommodation, the left not as well as the right. There was more on the right. Marked anesthesia was present in the also no apparent contraction of the visual fields. The tremor right lower extremity and the right half of the trunk, and a in the right upper extremity was most noticeable when moving hypesthesia in the hand and forearm. The special senses were from a resting position and it seemed to disappear at times unaffected. He died of an attack of acute pleurisy. when the arms were supported. It was very noticeable when sclerosis Plaques of which, from their position and extent, the arm was held free. The tremor was not rotary or rhythmic, explained the characteristics of the symptomatology and prog- but jerky and varying in amplitude. No pill-rolling motion of the found the cervical ress cases were in and thoracic cord. like that seen in paralysis agitans was present. The patient tended to hold the fingers somewhat flexed at the knuckles. UNILATERAL DESCENDING PARALYSIS IN DISSEMINATED The hand, arm and shoulder girdle showed no atrophy. All SCLEROSIS. movements of the upper extremity could be performed, but were the In rare instances, a form of more or less slowly de- affected by tremor. Slight tremor was present in the is that is, of be- right leg on its being moved, with no wasting of this extremity scending paralysis observed, paralysis and no the said that the in the arm and face and later the apparent shortening, although patient ginning involving leg. leg felt shorter than the other. Extension and flexion of the is to occur somewhat This, of course, known frequently foot were but than similar in right ample, more sluggish move- paralysis agitans, although after the plastic rigidity ments of the other foot. There was marked limitation of rota- with or without tremor has attacked one upper extrem- tion of the right leg; other movements were normal. Knee- ity it is perhaps just as likely to cross to the opposite leg jerk was increased on the right side; slight tendency to ankle as to pass to the leg of the same side. Dr. David Ries- clonus was shown and a marked Babinski reflex was present man, of Philadelphia, has furnished me with the notes on this side. Sensation was normal. The gait of the patient was the of a case which appears, when closely analyzed, to be one hémiplégie, right leg being dragged somewhat. Distinct of disseminated sclerosis in which the spastic right-sided ptosis is noted in one entry. The lungs, heart, blood, paralytic, abdominal viscera and all of the were in- and tremulous were first most marked in the parts body carefully phenomena vestigated, and notes of these examinations have been fur- So far as the limbs were upper extremity. concerned, nished me by Dr. Riesman, but as they seem to have no to the last notes were the affection was, up the time when special bearing on the man's nervous disease they have been made, unilateral in its distribution. Some question may omitted for the sake of brevity. arise in the consideration of this case as to whether it is Pupils 4 m.; irides react to light and accommodations; one of disseminated sclerosis of unilateral and descend- tension normal; in the right eye the media were clear and type or a form of slowly developing unilateral paraly- the disc pale, showing atrophie excavations; there was myopic ing 1 D. left sis due to meningomyelitis or some other form of spe- astigmatism, The eye was the same as the right. movements were It is stated in cific lesion. On the whole, however, it would seem to me Ocular unimpaired. the his- that the had fifteen before com- the which fits the case best is that of dis- tory patient diplopia years that diagnosis ing under notice, this having been corrected by glasses. seminated sclerosis, in the stage when the record was made, of unilateral and descending form. ASCENDING TYPE OF UNILATERAL AMYOTROPHIC LATERAL old The patient was a man forty-three years whose SCLEROSIS. father died of at the öf nephrolithiasis age sixty-three Unilateral lateral a his mother of at the of amyotrophic sclerosis, compara- and apoplexy age fifty-eight. rare form of is One brother was in an insane for two of tively amyotrophic disease, occasionally asylum periods this is not the rule. suc- úx months each. ascending, although Spiller9 ceeded in 10 cases of unilateral Case 12.—Patient had specific lesion at the age of collecting amyotrophic primary lateral of four were with 26, accompanied by alopecia and later by secondary eruptions sclerosis; these, necropsy. for Three of the ten were of on the abdomen, thorax and arms. He took medicine this ascending type (Vierordt, a disease for one year. He had pyelitis 8 years before coming Mott, Senator). To these is added case of his own, under observation, suffering from this affection for one year. with necropsy and microscopic examination. According to his statements, he is especially subject to erysipe- The in the lower he had about six in all. Two of the attacks paralysis began right extremity, las, which had times passed to the upper limb of the same side, and later to of erysipelas he had had within 18 months, the supraorbital the left lower the left and infraorbital affected. The most extremity, upper extremity being regions being patient's also involved. In this besides evident when he came to the hospital were partial eventually slightly case, symptoms and loss of motor power in the right upper and lower extremity, ac- spastic paralysis abnormally exaggerated reflexes, companied by violent coarse tremors of the extremities when considerable atrophy was present in the right upper ex- he attempted any movements of them. He limped somewhat tremity. Degeneration in this case was found in the with the right leg. He dated his present trouble to two years ventral horns as well as in the pyramidal tracts. It is when he to have a before he was seen, began dull heavy feeling at in some cases which with then to lose of the probable that, least, begin in the right shoulder. He began control right tract if the lives which loss of power was by trembling of the pyramidal degeneration, patient long arm, accompanied take in arm when he attempted to use it. He stated that within the enough the ventral horns eventually part the last year, that is, about a year after the onset of the paralysis degeneration; although, as already shown in the case and tremor in the arm, the right lower extremity had troubled recorded by myself in collaboration with Dr. Spiller,4 him because of a in this He had had loss of power part. sharp examination showed that the cells of the ven- in this lower He had been able to pathologic shooting pains extremity. tral cornua were involved to dark without Both bowel and bladder not any appreciable extent walk in the falling. this control had remained intact. He had never had any girdle in unique case. sensation. Consciousness had never been lost. After the publication of the paper bv Spiller, an addi- be somewhat monotonous, This showed his speech to tional case of amyotrophic lateral sclerosis, at first uni- with a tendency toward scanning speech; spasticity of marked intention tremor of the right leg, thigh and arm; 9. Spiller, William G.: Univ. Penna. Med. Bull., January and right upper extremity; fibrillary tremor of the tongue; some February, 1905.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 lateral and has been recorded Potts.10 flexes were everywhere greatly exaggerated on the right side, descending, by the and Both sides of the body were eventually involved, bulbar muscle tendon jerks of both arm and leg being carefully and examined. The right great toe remained permanently somewhat symptoms appearing becoming prominent. extended as in a case of Friedreich's ataxia. A marked Babinski DESCENDING TYPE OF UNILATERAL AMYOTROPHIC LATERAL reflex was present on this side, the already extended great toe SCLEROSIS. extending still further on plantar stimulation. Ankle clonus was on the right side. The and loss of Seven of the ten cases collected were of de- present wasting power by Spiller were not in left half of the 3 present anywhere the body. The scending type (Dejerine, Pick, Leyden, Lennmalm, reflexes, while prompt, were not exaggerated as on the other cases of Probst). Of these, five began with bulbar symp- side, and irritation of the sole of the foot gave normal plantar and lower toms, the paralysis of the upper extremities flexion. A very slight hypesthesia was present in the right arm coming on in succession, or at least later. In a case re- and trunk. The patient's mental condition was good. He had with bulbar symptoms, kept up with his class in a good preparatory school. He had ported by Dejerine, beginning neither the lower of the side affected was more continuous nor paroxysmal headache nor any other extremity evidences of focal disease. The than the In Pick's case case seemed to be clearly one markedly paralyzed upper. par- of unilateral first in the left limb and extended to amyotrophic lateral sclerosis beginning first in alysis began upper the upper extremity. the lower of the same side; later the right side became affected. In Leyden's case bulbar symptoms were first; UNILATERAL ASCENDING TYPE OF PARALYSIS AGITANS. later next weakness developed in the left upper limb and It is, of course, well known that paralysis agitans is In Lennmalm's case bulbar in the left lower extremity. often for a long time a unilateral affection ; it is not so symptoms were followed by loss of power in the ex- well understood that the unilateral form of this disease tremities of the right side and later by paralysis in the not infrequently is of ascending type, the disease passing left upper limb. from lower to upper extremity of the same side and In one of the several cases reported by Probst bulbar later to the lower and Patrick and lower extrem- opposite upper extremity. symptoms began first, the right upper regarded one of the cases described by me in 1900 as an ities involved. In another case reported by illustration of this affection rather than a case of becoming lower pri- Probst, weakness began in the left upper and mary degeneration of the pyramidal tracts, but of this limbs and later in the right upper. In still another case I have not been convinced. With to this matter followed regard of Probst's bulbar symptoms began first, by I need only reproduce here remarks made in a previous a short time weakness in the left upper extremity and in paper written in collaboration with Dr. William G. in the left lower extremity. Spiller:4 I of a case of Recently, had the opportunity studying Among the reasons for believing that the case was not paraly- unilateral amyotrophic lateral sclerosis of descending sis agitans were the absence of spontaneous tremor; the pres- type which it may be worth while to record in this con- ence of markedly exaggerated reflexes on the affected side, even nection, owing to the fact which has just been shown including ankle clonus and patellar clonus; the existence of that scarcely more than a dozen unilateral cases of this decided wasting on one side, especially of the lower extremity; and the of the of and of a disease have as been on record. absence faciès paralysis agitans fixed yet put of the and head. to Sir William Case 13.—A about 14, was in good health until position body According boy, aged Gowersu both lateral sclerosis and three before he was seen me for his family primary paralysis agitans about years by are and it be that in the under when he to have slight tremor in the right probably abiotrophies, may case physician, began consideration the two abiotic diseases are hand. About eighteen months to two years later some weakness conjoined. in the right leg was observed. Patrick5 reports a case of unilateral paralysis agitans Examination showed no particular difference in the two in his paper with the view of indicating; the similarity sides of the head and face. Ocular movements were normal, cf this case to that reported by me and reinvestigated as were also movements of the parts supplied by both the facial by him. In this case the disease began in the upper ex- and trigeminal nerves. The right upper extremity showed dis- later to the lower. impression is and and some was tremity, passing My tinct nearly generalized atrophy, wasting that this is rather the usual course, I have not in the right half of the trunk. The right thenar and although present made any collection of cases to demonstrate the point. hypothenar eminences were extremely wasted. The right lower Whether or not the case both Patrick and extremity, like the upper, was also generally smaller than the reported by left. Testing for special movements, weakness was found in all myself was one of paralysis agitans or of paralysis agi- parts of the limb, but this was much more decided in the prox- tans and pyramidal degeneration conjoint, it is certain imal than in the distal portions. The movements of the foot that Parkinson's disease may remain for a considerable on the leg and the movements of the toes were greatly impaired. time unilateral, and beginning in the lower extremity of the foot and toes was with Every possible movement tested, may take an ascending course. Recently. I have seen the result Farado-contractures were well preserved just given. two cases of this ascending type. on both sides; on the right side was a quantitative increase, Case 14.—A man, 55, a pattern maker, first began to the muscles generally responding to a current of less current aged notice stiffness or in movement in his left leg in on the than on the left side. A moderate current impairment strength right first and for some time there was no in- contractures in the general musculature December, 1904. At produced widespread volvement of the left extremity, but this gradually came of the arm, probably partial degeneration reaction. upper and at the time when he was first seen, about 16 months On movements of the right or atrophied arm the on, attempting after of the trouble in the the arm was had associated movements of the left. No matter what the beginning leg, very patient affected. He had occasional cramps in the legs, the movement was attempted with the right upper extremity, the markedly toes at times when these cramp-like feelings were left responded, sometimes in regular and some- contracting upper extremity He also had at after sitting, feelings times in a sort of forced athetoid,movement of the hand and present. times, especially or in the left and arm. fingers. Voluntary movements of the right lower extremity did of numbness tingling leg a fixed of the not cause movement in the left lower, but did cause some move- Examination showed rather position head, the left and ment in the left upper extremity. These, however, were by no slowness of gait with some dragging of foot, in left in the means as marked as when the voluntary effort was made with a marked tremor the upper extremity, especially the seen in Parkinson's disease. the upper right extremity. Both the deep and superficial re- hand, this being type usually Observed over short periods it was sometimes present and at 10. Potts, Charles S.: Univ. Penna. Med. Bull., July and August, 1905. 11. Gowers, Sir William: Lancet, April 12, 1902.

Downloaded From: http://jama.jamanetwork.com/ by a University of Kansas, Participant User on 07/11/2016 and a others absent, it was little increased by voluntary effort scending type, is rare, but, of course, may occur. Such or attention. While both the and arm on the affected side leg a case would either on the showed a little stiffness and awkwardness in movement, real probably depend degenera- tive neuritis or on the succession of lesions. loss of power was slight. The patient still continued to work peripheral The manner in which each of the at his business, even using the left hand. He said that if he stage paralysis ap- the state of the could get a good grip on an object with this hand he could go peared, reflexes, the results of electrical on using it in his work. Sensation was everywhere retained. examination, and other well-known methods of determin- Case 15.—A woman, aged 43, first observed weakness in the ing the existence of a peripheral nerve disorder would left lower extremity four years before coming under observa- serve to separate such a neural case from the forms of tion. Tremor did not appear for three years in the left lower progressive hemiplegia under consideration. The ab- extremity and shortly after this the upper extremity became sence of hysterical stigmata, as well as the slowly pro- involved, showing both weakness and tremor. Symptoms ap- gressive manner of appearance of the paralysis of leg, peared in the lower of the side three and a extremity opposite arm and face would make a hysterical im- half years after the beginning of the disease. The case was hemiplegia A pure neurasthenia never shows itself as a clearly one of paralysis agitans and need not be described at probable. length. slowly developed and permanent hemiplegia. It is not my intention to go with any elaboration into DISCUSSION. a discussion of the differential diagnosis of unilateral Dr. Herman H. Hoppe, Cincinnati, said he was very glad to ascending and unilateral descending paralysis from focal hear Dr. Mills increase the latitude of the subject. He re- lesions, cerebral or spinal, from ported a case perhaps of this kind that he had had under his cerebrospinal syphilis, care for about a or 18 A about and from or affections. For the sake year months. young child 3 or peripheral hysterical 4 years of age which first of a few words be said developed spastic paralysis, ap- completeness, however, may peared in the arm, and then descended to the leg and ascended about these In a rare case a brain tumor diagnoses. to the face. The child was absolutely healthy up to the age in the area or may originate cortical leg beneath it and of 2% years; it developed, intellectually and otherwise, nor- develop toward the arm and face regions so as to cause a mally, walked normally and looked like a normal child; then progressive hemiplegia of the ascending type. The re- it gradually developed paralysis, spastic in character, of the verse might, of course, take place, and the tumor origin- right arm, then spastic in character of the right leg, and then ating in or near the face or arm area and progressing of the face, during a period of perhaps six or eight months. In other the child was toward the center, a unilateral respects was perfectly well; there no leg give descending headache and the child ate and well. In such a case some or all of the slept One peculiarity paralysis. gen- about that no eral of brain tumor would be to be the case was there was absolutely syphilis, and symptoms likely the mother birth to other children who are well. The and other focal of this gave present, signs affection, espe- mother was addicted to drink, which was particularly mani- cially Jacksonian epilepsy, would sooner or later appear. fested before the child was born. Until Dr. Mills spoke of the A tumor of the internal capsule would most probably descending type Dr. Hoppe was very much puzzled about this produce loss of power in both arm and leg nearly simul- case. Whether there was any other feature about the case ianeously. In some cases of arteriosclerosis necrotic that would develop in the future he could not say. That par- areas form first in one and then in another portion of the ticular manner of development of spastic paralysis in a child brain, and it might happen that these would be so placed never occurred to him before. There was no history of any in succession^ in the motor region as to give unilateral infectious disease of any kind which might have caused an ascending or unilateral descending paralysis. Such a encephalitis. case would develop clinically by steps rather than by reg- ular progression, and other signs or symptoms indicat- ing the character of the lesions could probably be de- TECHNIC IN THE AFTER-CARE OF THE RADI- tected if sought for diligently. A single tumor or ne- CAL MASTOID OPERATION. crotic lesion of the cord would not cause a spinal paraly- PHILIP HAMMOND, M.D. sis from the to the as the cerebro- ascending leg arm, Aural Surgeon Massachusetts Charitable Eye and Ear Infirmary, spinal tracts passing to the nerve nuclei for the upper Instructor in Otology Harvard University. extremity do not proceed lower than the upper thoracic BOSTON. situated and region. Peculiarly peculiarly progressing To remove diseased tissue from the tem- focal lesions of the cervical cord simulate a uni- thoroughly might in cases of chronic is an lateral but the other well-known poral bone, suppuration, easy descending paralysis, task with the of a result- symptoms of such a unilateral focal lesion would be compared difficulty obtaining present and the subject hardly needs discussion. ant cavity absolutely free from granulations or dis- and lined with new To estab- The forms of spinal and cerebrospinal syphilis are charge, healthy epidermis. lish such a condition is an end toward which we protean. A spinal or intracranial gumma or gummatous speedily meningitis or a succession of focal syphilitic lesions are all striving. might give rise to a one-sided paralysis appearing first When the first radical operations were done in 1889, in the leg and afterward in the arm, and later taking the it was no uncommon thing to have suppuration continue form of a triplegia. This is, indeed, what occurs in some within the cavity for many months; healing was finally cases of meningitis or meningomyelitis with a secondary obtained only at the expense of much time and suffering, degeneration of the pyramidal tracts. The new case of and was usually attended with considerable deformity. unilateral ascending paralysis (Case 9), had some of To-day it is possible to have our exenterated cavity the features of a cerebrospinal syphilitic affection, al- thoroughly healed in a comparatively short time, in though the patient denied venereal disease. Close atten- many cases only five weeks, and with absolutely no post\x=req-\ tion to the history, and the presence of other evidences aural deformity, only a fine linear scar marking the line of syphilis and the variable and irregular manner in of incision. which the paralytic symptoms appear will assist in Read in the Section on Laryngology and Otology of the differentiating. American Medical Association, at the Fifty-seventh Annual Session, A paralysis of peripheral origin, of ascending or de- June, 1906.

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