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G. H. MONRAD-KROHN. M.-N. Kl. 



small muscles of the leet and, as a rule, a complete absence of spastic 

 phenomena. When the degenerativ^e process of the spinal muscular atrophy 

 extends to the motor cranial nuclei, in other words, when there is a 

 progressive bulbar paralysis, the disturbance generally afifects the tongue 

 before the face. The d3'sarthria is generally very pronounced, and the early 

 deficiency of the lingual sounds is generally a marked feature, whilst in 

 leprosy dysarthria is, as a rule, never very marked, and practically always 

 confined to the labial sunds, as we have already seen. When in bulbar 

 paralysis the face is affected, the upper portion of the face commonly re- 

 mains intact, whilst in leprosy it is the chief seat of motor deficiency. The 

 chief point of distinction from all these conditions of progressive degenera- 

 tion of the motor system (progressive spinal muscular atrophy, amyotrophic 

 lateral sclerosis, progressive bulbar paralysis, progressive ophtalmoplegia), 

 is however furnished by the sensory examination. In all these conditions 

 there is never any sensory loss, and, as we have seen, this is a common 

 and characteristic feature of leprosy. 



The distinction between lepros}' and the peroneal or progressive neu- 

 ritic muscular atrophy (Charcot, Marie, Tooth) may perhaps be more 

 difficult. Here all four limbs are affected in the same way by atrophy and 

 paresis of the distal parts. There may even be slight sensory disturbances 

 corresponding to the atrophic parts (below the knees and elbows); but these 

 sensory disturbances are never so pronounced as in leprosy. The facial 

 muscles escape in this disease. 



Myasthenia gravis, which may occasionally simulate the most varied 

 conditions, will easily be distinguished by its great diurnal variations. 



A cervical rib, by causing a longer brachial plexus lesion, may sometimes 

 give rise to disturbances in the upper limb which may resemble those found 

 in leprosy. One generally finds atrophy of the intrinsic muscles of the 

 hand and sensory loss along the ulnar border of hand and forearm. It has 

 to be kept in mind that the symptoms of cervical rib may arise at any 

 age. As a rule they begin when the patient has taken up some new occu- 

 pation necessitating the carrying of heavy weights (e. g. buckets of water), 

 this function pressing the lower fibres of the brachial plexus against the 

 cervical rib. Sometimes also a cervical sympathetic syndrom (miosis, 

 enophtalmus, pseudoptosis) occurs, and this forms then an important point 

 of distinction from leprosy. Another point of distinction is that the condi- 

 tion is confined to one upper limb, while leprosy generally attacks the 

 distal parts of all 4 limbs. An X-ray picture will decide the question of 

 cervical rib. 



The thickening of the nerves is a finding which also helps in di- 

 stinguishing leprosy from all the above-mentioned conditions. 



The most difficult distinction is probably that of leprosy from poly- 

 lu'uritis due to other causes. What makes this very difficult is that thick- 



