Patient cannot speak nor protrude the tongue out of his mouth and swallows only a small amount of fluid, which has to be passed deeply into the pharynx. Internal organs, especially the liver o.k. Urine o.k., Blood and spinal fluid W-R negative. Spinal fluid: no cells, globulin 0.34 mg. in i cc. sugar 67 mg. per 100 cc. Hyperkinetic Forms. Of purely hyperkinetic forms there were 20 such cases with finest galvanoid muscular contractions in the face, increasing at voluntary movements, or others, in which the myoclonus was more marked as regular, more or less strong contractions in the flexor area of the extremities or in the back muscles. In four cases rhythmic contractions of the neck muscles were present, which resulted in very annoying, nystagmus like lateral movements of the head. Three patients displayed clonic contractions in both masseter muscles with continuous up and down movements of the lower jaw; in one case these symptoms were unilateral. The majority of these patients came to the clinic only on account of the abnormal movements and when examined no other changes could be found. Only after careful inquiries the connection with a previous illness with lethargy, double vision and other symptoms could be elicited. All grades could be observed from the most minute tremor of the hands scarcely being visible but still disabling the patient from writing, to coarse extensive choreiform movements. of one or several extremities which, in some cases, were only unilateral. In a few cases, especially when the patients were excited, these movements became very violent and developed into attacks of a general shaking tremor of the whole body, followed by profuse sweating and prostration. Acute Forms. Of acute forms in development twenty-five cases were admitted, three of them died a few days after the onset with very grave symptoms. General malaise in the beginning, fever, headache, nausea, joint pains, tired feeling and sleepiness were the common complaints. Eye symptoms were of the earliest signs that usually appeared, especially double vision, later speech and swallowing became difficult, in a few cases a scarlatinoid rash of short duration was observed. After the initial feverish stage had subsided rhythmic muscular muscular contractions often appeared especially in the face, or they existed as a condition of a sort of latent myoclonus only; the contractions would readily appear upon the slightest mechanical stimulation or after a spontaneous voluntary movement of the respective muscles. Twice I saw unilateral facial paralysis, but never combined with the involvement of the acoustic nerve, as we see it so often in the syphilitic neuro recidiv. In one case the sixth nerve was paralysed. In nearly all cases the oculomotor symptoms persisted for a long period, mostly as ptosis and loss or weakness of convergence. The following very instructive case with post mortem findings represents the grave acute form: No. 73. Missionary. aet 26. Admitted October 30, 1924. A fortnight ago symptoms of bronchitis; patient thought to be suffering from influenza. 20. Oct. double vision, 24 Oct. pain in the forehead, 26. Oct. first day, at which the patient felt really ill. 27. Oct. great fatigue, vomiting. 28. Oct. double vision; consulted an eye specialist, who could not find any pathological changes, 29. Oct. Sleepiness, slight fever, eyes can scarcely be kept open. 30 Oct. admission: slight lethargy, ptosis r > 1. pupils r < 1, light reaction preserved, accommodation absent, speech slow, undistinct; salivation increased, movements slow, stiff; muscular tonus increased. No pyramidal tract symptoms. Sensibility, reflexes, sphincters o.k. Blood: W-R. neg. Spinal fluid: W-R. neg. 13 cells, total protein 0,96 mg per cc.; sugar: 58 mg per 100 cc. Colloidal gold: 001210, mastix: 1100. Course: Lethargy increasing, ptosis more marked, cramp-like pains in the joints, myoclonus of lips. Temperature between 102°F 104°F. 6. Nov. Exitus after increasing somnolence and raise of temperature to 106.8°F. Anatomical findings: Brain macroscopically o.k. except slight discolouration of both substantiae nigrae. Microscopic findings: Extensive cellinfiltration within and around the vascular sheaths, small cell infiltration in the tissue. These histological changes are most marked in both substantiae nigrae, the ganglion cells there showing extensive degeneration. Similar areas of infiltration are found ventrally of the aquaeduct of Sylvius round the ganglion cells of the oculomotor nucleus and still further distally penetrating the fibres of the root of the third nerve itself. The red nuclei are entirely free and also the pedes pedunculi, but the medial longitudinal bundle and the crossing fibres from the tegmentum are slightly infiltrated. The inflammatory process rapidly decreases cephalad as well as caudat. In the globus pallidus there are only a few perivascular infiltrations to be found and in the pons a few scattered areas between the pontine nuclei; nucleus dentatus and medulla are free of changes. Bulbar Forms. Besides the small epidemics of acute cases in Peitaiho which were mentioned above we observed a small epidemic of 15 cases of a quite benign character in Peking from January to March 1924. More than half of these cases (9) were women. Fever was either entirely absent or present only in a slight degree, but nearly in all cases bulbar symptoms were found besides ptosis |