49646ournal ofNeurology, Neurosurgery, and Psychiatry 1997;62:496-500

The role of weakness of surae muscles in J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.5.496 on 1 May 1997. Downloaded from astasia without abasia

Kenji Hachisuka, Akio Ohnishi, Makio Yamaga, Koichiro Dozono, Mari Ueta, Hajime Ogata

Abstract weakness and sensory disturbance of the lower Objective-To investigate the role of limbs caused by peripheral neuropathies, weakness of the bilateral triceps surae spinal root or spinal cord lesions, and muscles-the gastrocnemius and soleus myopathies. The symptom was named "asta- muscles-in astasia without abasia and sia without abasia" by Hirayama et al l 2 and is whether compensating for muscle weak- defined as an inability to maintain a stationary ness with ankle- orthoses improves position to assume and keep an upright pos- this disability. ture, although the legs are under control in Design-Case-control study of clinical walking. No other reports of the disability have findings and before and after trial of been found. As a patient with astasia without ankle-foot orthoses. abasia resembles a child on stilts who walks Setting-Clinics of the departments of steadily but continuously steps forward and rehabilitation medicine of two university backward while trying to stand in place, it is hospitals. also called the "stilts phenomenon."' 2 Patients-A stilts group consisting of 23 Hirayama et a12 suggested that astasia without patients with astasia without abasia, and abasia is caused by a combination of three a non-stilts group without this phenome- conditions: (1) loss of the ankle pattern of pos- non consisting of 12 patients with heredi- tural movements because of decreased muscu- tary motor sensory neuropathy, 15 lar strength and tone about the ankle joints; patients with lumbosacral spondylotic (2) lack of compensatory postural movements radiculopathy or spondylolisthesis, and 20 by the hip pattern, which is dependent on suf- healthy volunteers. ficient strength about the hip joints; and (3) Main outcome measure-Clinical find- impairment of somatosensory feedback from ings of the stilts and non-stilts groups the legs for postural stabilisation. were compared and the sensitivity and We have noticed that a patient who had specificity of each clinical finding was cal- weakness of the bilateral triceps surae muscles culated. The length of the centre of foot without sensory disturbances had astasia with- pressure (COP) while standing was mea- out abasia that improved with ankle-foot sured in a bilateral below amputee orthoses. Therefore, we examined patients and 16 consecutive patients in the stilts who had and others who did not have astasia group with and without ankle-foot without abasia to determine what part weak- http://jnnp.bmj.com/ orthoses. ness of the triceps surae muscle-which is Results-Weakness of the triceps surae composed of gastrocnemius and soleus mus- muscles was the only finding that differed cles-plays in astasia without abasia and Department of significantly between the two groups and whether compensating for the muscle weak- Rehabilitation Medicine was both sensitive and specific. The ness with ankle-foot orthoses reduces this dis- K Hachisuka amputee was unable to stand in place ability. K Dozono without dorsiflexion bumpers, which on October 2, 2021 by guest. Protected copyright. M Ueta functioned similarly to the triceps surae H Ogata muscle. Bilateral ankle-foot orthoses Patients and methods Department of Neurology, University improved the COPs of 14 out of 16 This investigation consisted of three studies: of Occupational and patients. statistical analysis of physical findings of Environmental Health, Conclusion-The main cause of astasia patients with astasia without abasia; measure- Japan A Ohnishi without abasia is weakness of the triceps ment of the stability of a bilateral below-knee surae and this is amputee while and evaluation Department of muscles, disability standing; of the Rehabilitation improved by bilateral ankle-foot orthoses. efficacy of ankle-foot orthoses. Medicine, Faculty of Medicine, Kumamoto (J Neurol Neurosurg Psychiatry 1997;62:496-500) STUDY 1 University M Yamaga Clinical criteria for astasia without abasia were Correspondence to: devised by two of us (KH and MY) as follows: Dr Kenji Hachisuka, Keywords: astasia without abasia; disturbance of (1) a patient can keep the body more stable Department of Rehabilitation stance; stilts phenomenon; peripheral neuropathy Medicine, University of while walking than while standing and (2) a Occupational and patient takes a step or must be supported Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Although it is generally thought that a person within one minute after beginning to stand in Kitakyushu, 807, Japan. who is able to walk is able to stand, we have place. Astasia without abasia was considered Received 24 September 1996 encountered patients who are able to walk but mild when a patient fulfilled only the first crite- and in revised form 18 December 1996 unable to stand in one place. This curious dis- rion and was considered severe when a patient Accepted 8 January 1997 ability can occur in patients with muscular fulfilled both criteria. Twenty three consecu- The role of weakness oftriceps surae muscles in astasia without abasia 497

tive patients with astasia without abasia (stilts evaluated as 5, 4, 3, 2, 1, or 03; muscle weak- group) were identified from among patients ness was defined as muscle strength of 2 or J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.5.496 on 1 May 1997. Downloaded from who were referred to clinics at the Department less. Range of motion of the ankle joint was of Rehabilitation Medicine, University of measured with a goniometer,4 and limitation Occupational and Environmental Health of the range of motion was defined as a range of Hospital, and at Kumamoto University motion of 50 or less. Muscle stretch reflexes of Hospital for further rehabilitation from 1988 the knee and ankle were elicited with a ham- to the end of 1995. Clinical diagnoses of mer, and absent or diminished reflexes of the patients were previously established at the knee and absent reflexes of the ankle were departments of neurology or orthopaedic defined as diminution of the muscle stretch surgery as follows: hereditary motor sensory reflex.5 Touch and pain on the dorsum of the neuropathy (five patients); spinal progressive foot and position and vibration sense of the muscular atrophy (two); acute inflammatory great toe were rated as "severely disturbed," demyelinating polyradiculoneuropathy (two); "moderately disturbed," "slightly disturbed," familial amyloid polyneuropathy (two); heredi- or "normal",) and a sensation of less than nor- tary sensory autonomic neuropathy (one); vas- mal was defined as sensory disturbance. culitic neuropathy (one); beriberi (one); Coordination of the lower limbs was rated as peripheral neuropathy of unknown aetiology "disturbed," "slightly disturbed" or "nor- (two); distal myopathy with rimmed vacuoles mal",5 and coordination of the less than nor- (one); myotonic dystrophy (one); cauda mal was defined as ataxia. Each result of the equina injury (two); lumbosacral spondylotic tests was converted into "no disturbance," radiculopathy (one); spondylolisthesis (one); "unilateral disturbance," or "bilateral distur- and myelomeningocele (one). bance" to allow use of the x2 test. Forty eight subjects who did not fulfil the For the five patients in the stilts group in criteria for astasia without abasia (non-stilts whom sensory disturbances were not found group) consisted of 12 patients with hereditary during physical examination, sural con- motor sensory neuropathy (NS-HMSN), 15 duction velocities,6 somatosensory evoked patients with lumbosacral spondylotic radicu- potentials (SEPs) to stimulation,7 lopathy or spondylolisthesis (NS-LSR), and and cutaneous vibration and thermal cooling 20 healthy control subjects (NS-C). The NS- thresholds8 were evaluated to confirm the HMSN group consisted of consecutive presence or absence of sensory abnormalities. patients referred to the clinic at the Department of Rehabilitation Medicine for STUDY 2 gait training. The NS-LSR group consisted of To study whether compensating for weak tri- consecutive patients referred to the clinic for ceps surae muscles improves stability while muscle strengthening and gait training after standing, the length of the centre of foot pres- surgery of the lumbar spine, and had weakness sure (COP) was measured in a patient who in the unilateral tibialis anterior or triceps had had both legs amputated below the knee surae muscles or both. The NS-C group con- five years earlier because of frostbite. The sisted of volunteers who had never had neuro- patient had normal muscular strength in the muscular disorders. lower limbs; had no disturbances of touch, was Neuromuscular testing performed with pain, position, or vibration sense of the http://jnnp.bmj.com/ standard techniques in all subjects. Muscle stumps; and was able to walk and run with strength of the , , prostheses.9 Results of SEP studies were nor- quadriceps femoris, , tibialis ante- mal. The COP was taken as the projection of rior, and triceps surae muscles was manually the centre of gravity on to the force plates (Kistler, Switzerland), on which the amputee stood for 30 Figure 1 The below-knee seconds with the artificial feet prosthesis. The lateral half (SuperankleC, LAPOC, Japan) maintained at of the artificialfoot is 400 between the feet and the eyes open. Each on October 2, 2021 by guest. Protected copyright. removed to show the mechanism ofthe measurement was repeated five times before superankle. The and after dorsiflexion bumpers, which pre- dorsiflexion bumper vented excessive dorsiflexion of the feet, were supports the shaft and prevents excessive attached to the feet (fig 1). The COPs were dorsiflexion while standing. expressed in cm/30 s, and the average was calculated with a personal computer (PC9801BA, NEC, Japan). When the amputee took a step or was supported by members of the medical staff during the mea- surement at least once per five trials, the COP was defined as unmeasurable.

STUDY 3 Ankle-foot orthoses'0 were fitted for 22 patients in the stilts group to improve stability while standing; a foot orthosis'° was made for one patient because of ulcers on the bottom of the feet. Patients subjectively evaluated stability while standing with orthoses as worse, unchanged, improved, and much improved. 498 Hachisuka, Ohnishi, Yamaga, Dozono, Ueta, Ogata

Comparison ofclinicalfindings between the stilts and non-stilts groups Results J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.5.496 on 1 May 1997. Downloaded from Stilts Non-stilts STUDY 1 group group In the stilts group patients had peripheral neu- (n = 23) (n = 47) P value Sensitivity Specificity ropathies, spinal root lesions, or distal domi- Muscular weakness: nant myopathies, and astasia without abasia Bil gluteus maximus 5 1 0-006 0-83 0 72 Unil gluteus maximus 0 6 0-168 0 00 0-64 was mild in 15 patients and severe in eight. Bil tibialis anterior 18 4 < 0 001 0-82 0 90 Differences in age were not significant either Unil tibialis anterior 0 4 0-150 0 00 0-65 Bil triceps surae 22 1 < 0 001 0-96 0-98 between the stilts (mean (SD) 45 9 (18-1) Unil triceps surae 0 5 0-164 0 00 0 65 years,) and non-stilts groups (40 4 (12.3) Iimitation of range of motion: Bil ankle joints 2 6 0-615 0-25 0 66 years; df = 68, t = 1-51, P = 0-136) or Unil ankle joint 0 1 1 000 0 00 0 67 among the three subgroups of the non-stilts Diminution of muscle stretch reflex: group (NS-HMSN, 37-2 (13-6) years; NS- Bil knee joints 15 13 0-003 0 54 0 81 LSR, 39-7 (13-9) years; NS-C, 42-8 (10-4) Unil knee joint 0 1 1 000 0 00 0 67 Bil ankle joints 23 13 < 0 001 0 64 1 00 years; df = 46, F = 0-788, P = 0-461). Sex Unil ankle joint 0 14 0 003 0 00 0 59 ratios (male:female) did not differ significantly Sensory disturbances: Touch on bil dorsi 16 16 0 005 0 50 0 82 between the stilts (10:13) and non-stilts Touch on unil dorsum 0 8 0-046 0 00 0 63 groups (28:19; df = 1, X2 = 1-612, P Pain on bil dorsi 16 16 0 005 0 50 0 82 Pain on unil dorsum 1 8 0 254 0 11 0 64 0 204). Position of bil toes 15 12 0 001 0 56 0 81 In the stilts group at least 18 patients (75%) Position of unil toe 0 6 0 076 0 00 0 64 Vibration on bil toes 17 15 0 001 0 53 0 84 showed weakness in the bilateral tibialis ante- Vibration on unil toe 0 6 0 168 0 00 0 64 rior and triceps surae muscles and diminution Muscular weakness of the iliopsoas, quadriceps, and hamstrings, and coordination are not of muscle stretch reflexes of the bilateral shown because of low frequencies. bil = bilateral; unil = unilateral; dorsi = dorsi of the feet; ankles (table). Although 11 clinical findings dorsum = dorsum of the foot; toe(s) = big toe(s). were significantly different between the stilts and non-stilts groups (x2 test, P < 0 05), only The COP was also measured in 16 consecu- one, with weakness of the bilateral triceps tive patients in the stilts group. surae muscles, had both sensitivity and speci- ficity that exceeded 0 95. STATISTICAL METHODS Five patients of the stilts group in whom Student's t test and one way analysis of vari- sensory disturbances were not found during ance (ANOVA) were used to examine the dif- physical examination had mild astasia without ferences in age between the stilts and non-stilts abasia. Results of sural nerve conduction groups and among the NS-HSMN, NS-LSR, velocity and SEP testing were normal in all and NS-C groups. The X2 test was used to five patients, and cutaneous vibration and detect any difference in sex ratio between the thermal cooling thresholds were normal in two groups. Each clinical finding between the three. two groups was compared using the X2 test and Fisher's exact test, if necessary. Sensitivity was STUDY 2 the rate of patients with astasia without abasia The bilateral below-knee amputee was able to among those having a finding, and specificity stand in place while wearing prostheses and was the rate of patients without astasia without had a COP of 510 (4 3) cm/30 s. After the those not a finding. dorsiflexion bumpers were detached from the abasia among having http://jnnp.bmj.com/ Student's t test was used to compare COPs prostheses, he was unable to stand in place between trials with and without orthoses. and took a step; therefore, the COP was unmeasurable.

STUDY 3 Undetectable -o I U U With ankle-foot orthoses, stability while stand- ing was subjectively judged as much improved

by 17 patients, and as improved by five on October 2, 2021 by guest. Protected copyright. 140 H patients. The COPs decreased greatly in seven 0 of the 16 consecutive patients while wearing r;) [- CD 120 ankle-foot orthoses (Nos 3 to 9 in fig 2), E decreased significantly in another seven a-- 100 H 0 11 patients (Nos 10 to 16), and were unmeasur- C- 0 11 able either with or without orthoses in two 80K- * 7* 0 b 0 (Nos 1 and 2), although the patients claimed b 60 improvements. Astasia without abasia was 0 severe in the two patients (Nos 1 and 2) who 40 had severe sensory disturbances and was mild

l in three patients (Nos 11, 13, and 16) who 1 2 3 45 6 7 8 9 10 11 12 13 14 15 16 had no sensory disturbances. No of patients Figure 2 The COP values of 16 consecutive patients in the stilts group with and without Discussion ankle-foot orthoses. Each patient's COPs with and without ankle-foot orthoses were linked. The COPs decreased considerably in seven patients while wearing ankle-foot orthoses (Nos Because astasia without abasia is encountered 3 to 9), decreased significantly in another seven (Nos 10 to 16), and were unmeasurable in various conditions, this study included (patient took a step or was supported at least once perfive trials) either with or without patients with hereditary motor sensory neu- orthoses in two (Nos 1 and 2), although the patients claimed improvements. COP = average length of the centre offoot pressure (cm/30 seconds); * = without orthoses; [ = ropathy or spinal root lesions who did not with orthoses; P < 0 05; Student's t test. show astasia without abasia and healthy volun- The role of weakness of triceps surae muscles in astasia without abasia 499

teers. As there were no significant differences requires continuous muscular activity of the in age and sex ratio between the stilts and non- triceps surae muscle.'2 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.5.496 on 1 May 1997. Downloaded from stilts groups, their clinical findings could be Lack of compensatory postural movements compared to investigate physical factors con- of the hip has been postulated as one of the tributing to astasia without abasia. three conditions contributing to astasia with- Hirayama et al 12 reported that the cause of out abasia."2 The postural movements sup- astasia without abasia was a combination of porting the erect stance are organised by using the loss of the ankle pattern, lack of compen- one or a combination of two basic patterns: satory movements of the hip, and impairment those of the ankle or the hip." The dominant of somatosensory feedback from the legs. frequencies of postural sway in the patient's However, one patient with progressive spinal upright posture are about 1 Hz,2 which is iden- muscular atrophy and astasia without abasia tical to the mechanically limited frequencies of had neither weakness of the hip extensor and the centre of gravity sway when pure hip pat- flexor muscles nor sensory disturbance of the tern postural movements are used. 14 lower limbs." Therefore, we hypothesise that Considering that 18 patients who had astasia the most important factor in the development without abasia did not show any weakness of of astasia without abasia is weakness of the tri- the gluteus maximus muscles (table) and ceps surae muscles although disturbance of results of the amputee study, the 1 Hz oscilla- compensatory postural movements and tion in the upright posture may not suggest a impairment of sensations are aggravating fac- disturbance of postural movements but com- tors. pensation of a process by the hip pattern. In this study the weakness of the bilateral Although our study found that an impair- triceps surae muscles was the only one of 28 ment of sensation is not required for this dis- physical findings that was both sensitive and ability to develop, balance control requires specific for astasia without abasia. Moreover, continuous regulation and integration of sen- as patients without sensory disturbances and sory inputs.'5 Because patients in the stilts without weakness of the iliopsoas and gluteus group with severe sensory disturbances were maximus muscles also had astasia without very unstable while standing and patients abasia, these findings also support our sugges- without any sensory disturbance were slightly tion that neither impairment of somatosensory unstable, impairment of sensation likely wors- feedback nor disturbance of compensatory ens astasia without abasia. As a patient who postural movements is essential for astasia had sensory disturbances and no muscular without abasia. weakness was not included in this study, it is Although we suggest that weakness of the unclear whether sensory disturbance without triceps surae muscles causes astasia without muscle weakness can cause astasia without abasia, proving that it does so regardless of abasia. However, we think that such a patient compensatory postural movments of the hip would be unstable while both walking and and somatosensory feedback from the legs is standing in place-that is, sensory ataxia. difficult. The bilateral below-knee amputee is The treatment for astasia without abasia one of the best models for investigating the consists of treatment of the underlying condi- effect of the strength of the bilateral triceps tion, if possible, and compensatory therapy for

surae muscles on stability while standing with the weakness of the triceps surae muscles to http://jnnp.bmj.com/ normal compensatory postural movements of maintain an upright posture. We suggest that the hip and constant sensory input from the ankle-foot orthoses should be prescribed for legs. Firstly, we selected an amputee who was patients with this disability to prevent inappro- thought to have no impairment of compen- priate ankle dorsiflexion while standing and satory postural movements or somatosensory orthoses are the best method to improve feedback. The amputee had normal muscular standing balance. strength, sensations, and SEP results and did not have any of We thank Drs Kazuhiro Inoue and Kumiko Inuyama, on October 2, 2021 by guest. Protected copyright. disability standing or walking Department of Rehabilitation Medicine, University of while wearing prostheses. Secondly, to mimic Occupational and Environmental Health, for referring some weakness of the triceps surae the patients to us; Saburo Ohmine, Hideo Shitama and Koichi muscles, dor- Shinkoda, Rehabilitation Center, University of Occupational siflexion bumpers were detached from the arti- and Environmental Health Hospital, for measuring the centre ficial feet. The of foot pressure; and Dr Noboru Iwata, Department of bumpers continuously support Ergonomics, University of Occupational and Environmental the shafts of the prostheses and prevent exces- Health, for statistical review. sive ankle dorsiflexion while standing. Because they function similarly to the triceps surae 1 Hirayama K, Kawamura M. Astasia without abasia (able to muscle, detaching the bumpers can mimic walk and unable to stand still) a strange disturbance of complete paralysis of the bilateral standing induced by peripheral neuropathy. Clin Neurol triceps surae 1991;28:1357-66. muscles. As the interface between the socket 2 Hirayama K, Nakajima M, Kawamura M, Koguchi Y. and stump is unaltered before and after Astasia without abasia due to peripheral neuropathy. Arch Neurol 1994;51:813-6. detaching the bumpers, transmission of tactile 3 Daniels L, Worthingham C. Muscle testing. techniques of information from the to manual examination. 3rd ed. Philadelphia: Saunders, prostheses the stump 1972. is considered constant. Therefore, an inability 4 American Academy of Orthopedic Surgeons. joint motion: to stand without the dorsiflexion bumpers method of measuring and recording. Chicago: American Academy of Orthopedic Surgeons, 1965. indicates that the muscular strength of the 5 Haerer AF. Dejong's the neurologic examination. 5th ed. bilateral triceps surae is essential to maintain a Philadelphia: Lippincott, 1992. 6 Kimura J. Electrodiagnosis in diseases of nerve and muscle. straight posture while standing. Results of this Philadelphia: Davis, 1983. amputee study are consistent with 7 Uozumi T, Tsuji S, Sasaki M, et al. Somatosensory evoked Basmajian's potentials in patients with cervical spondylotic myelopa- belief that maintaining a standing position thy. Clin Neurol (Tokyo) 1989;29:558-62. 500 Hachisuka, Ohnishi, Yamaga, Dozono, Ueta, Ogata

8 Ohnishi A, Ikeda M, Yamamoto T, Murai Y. Cutaneous Medicine 1994;31:346-9. vibration and thermal-cooling threshold in control 12 Basmajian JV. Lower limbs. In: Basmajian JV, De Luca CJ, J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.62.5.496 on 1 May 1997. Downloaded from subjects. Sangyo Ika Daigaku Zasshi 1988;10:283-7. ed. Muscle alive. 5th ed. Baltimore: Williams and Wilkins, 9 Friedmann LW. Rehabilitation of the lower extremity 1985:336-8. amputee. In: Kottke FJ, Lehmann JF, eds. Krusen 's hand- 13 Horak FB, Nashner LM. Central programming of postural book of physical medicine and rehabilitation. Philadelphia: movements: adaptation to altered support-surface config- Saunders, 1990:1024-1101. urations. J Neurophysiol 1986;55:1369-81. 10 Lehmann JF. Lower limb orthotics. In: Redfor JB, ed. 14 Nashner LM, Shupert CL, Horak FB, Black FO. Organiza- Orthotics etcetera. Baltimore: Williams and Wilkins, 1985: tion of posture controls: an analysis of sensory and 198-351. mechanical constraints. Prog Brain Res 1989;80:411-8. 11 Ueda M, Tsutsui Y, Inoue K, Hachisuka K, Ogata H. 15 Lajoie Y, Teasdale N, Bard C, Fleury M. Attention Plastic AFOs for spinal progressive muscular atrophy demands for static and dynamic equilibrium. Exp Brain with stilts phenomenon. Japanese Journal of Rehabilitatory Res 1993;97: 139-44.

Octave Landry's ascending paralysis and the Landry-Guillain- Barre-Strohl syndrome

Continuedfrom p495 eponym Landry-Guillain-Barre syndrome.'0 But Guillain was angered by the inclusion of Landry's But it was not until 1916 that the next major contri- name,"I arguing that Landry's acute bulbar form was a bution materialised, as the celebrated paper by separate condition, and since lumbar puncture was not Guillain, Barre, and Strohl describing the illness in two practised until 1891 (Wynter and Quincke) before French soldiers.9 Landry's time, that the inclusion of his name was "une confusion absolue". "The syndrome is characterised by motor disorders, aboli- nosographique tion of the reflexes with preservation of the cuta- Barre, a fine clinician, became professor of neurol- neous reflexes, paraesthesias with slight disturbance of ogy in Strasburg, concentrating his research on objective sensation, pain on pressure of the muscle masses, vestibular disorders. He died in 1967. marked modifications in the electrical reactions of the Landry, living for a time in straitened circum- http://jnnp.bmj.com/ and muscles, and remarkable hyperalbuminosis of the cere- stances, had made no further contributions to the sub- brospinal fluid with absence of cytological reaction (albu- ject. His wife, Claire Giustigniani, he described as: minocytological dissociation). "d'une grande beaute, d'une distinction supreme, mais This syndrome seemed to us to depend on a concomitant beaucoup plus riche de noblesse que d'argent". A gen- injury of the spinal roots, the nerves, and the muscles, prob- ably of infectious or toxic nature." tle and modest man, he directed a hydrotherapy clinic for nervous diseases at Auteuil, which eventually The soldiers described both showed gross elevation brought its own success and financial reward. A gifted of cerebrospinal fluid protein (2-5 g/l in the first case) exponent of the violoncello, he was also an accom- without a cellular reaction. Strohl, whose name is often plished singer and dancer. He cut an elegant and pop- on October 2, 2021 by guest. Protected copyright. overlooked, performed the electrophysiological tests ular figure in artistic salons. But he was no lounge ("myographic curve"). Osler's 1892 classic The princi- lizard, occupying his leisure as alpinist, geologist, ples andpractice ofmedicine recognised the illness, calling horseman, and huntsman. Sadly, in his 40th year, it acute febrile polyneuritis, and Bradford, Holmes, Landry attended the penniless, destitute victims of a and others regarded it as acute infective polyneuritis. cholera epidemic in Paris, contracted the illness him- In 1949 Haymaker and Kemohan commended the self, and died a few days later. JMS PEARCE 304 Beverley Road, Anlaby, East Yorks HU10 7B7, UK

1 Landry 0. Note sur la paralysie ascendante aigue. Gazette 1884:574; 579-80. Hebdomadaire de Medicin 1859;6:472-4; 486-8. 8 Dumenil L. Paralysie peripherique du mouvement et du 2 Wilks S. Lectures on diseases of the nervous system delivered at sentiment portant sur les quatre membres. Atrophie des Guy's Hospital. London: Churchill, 1878. rameaux nerveux des parties paralysies. Gazette 3 Leyden E von. Ueber poliomyelitis und neuritis. Z klin Hebdomadaire de Medicin 1864;1:203-6. Med 1879/80;1:387-8. 9 Guillain G, Barrn JA, Strohl A. Sur un syndrome de 4 Bontius J. De medicina indorum (1642). English transla- radiculo-nevrite hyperalbuminose du liquide cephalo- tion 1769, chapter 1, book IV: cited In: Ralph H Major. rachidien sans reaction cellulaire. Bull Soc Med Hop Paris Classic descriptions of disease. 3rd ed. Oxford: Blackwell, 1916;40:1462-70. 1945:605. 10 Haymaker W, Kemohan JW. The Landry-Guillain-Barre 5 Pearce JMS. Robert Graves and multiple neuritis. J Neurol syndrome: a clinicopathologic report of fifty fatal cases Neurosurg Psychiatry 1990;53:113. and a critique of the literature. Medicine 1949;28: 6 Chomel A-F. De l'epidemie actuellement regnante a Paris. 59-141. Jf Hebdomadaire de Medecin 1828;1:333 et seq. 11 Guillain G. Radiculoneuritis with acellular hyperalbu- 7 Graves RJ. Clinical lectures on the practice of medicine. 2nd minosis of the cerebrospinal fluid. Arch Neurol Psychiat ed. reprinted by New Sydenham Society, London, 1936;975-90.