Ml' LTIGIAKDULAK SYNDROMES 907 



anticus was among the first muscles to cause trouble. The most prominent 

 symptom was the disturbed -muscular function ; in the mildest cases being 

 stiffness and rapid exhaustion, going to absolute paralysis of single muscles, 

 or entire groups in severe cases. The involvement was symmetrical. In 

 most of the cases the diseased muscles gradually disappeared or atrophied, 

 and hypertrophy was very rare. Frequently there was a lordosis with 

 winged scapulae, with protrusion of the shoulders or flattening of the chest. 

 Fibrillary twitching was rare, being seen only once in fact. There was in 

 the skin occasionally los$ of pigment or abnormal coloring. Of the 

 eleven subjects who died while under Barsickow's observation, one was 

 over 80 years of age, four over TO years, three over 60, one 58 and two 33. 

 Hence the disease apparently did little to cut short their lives. 



Taking up Barsickow's individual cases, those that showed symptoms 

 seemingly not accounted for in the usual syndrome of dystrophia mus-, 

 culorum progressiva, we see in his Case 1 the complaint of rheumatoid 

 pains in many parts of the body, dirty brown pigmented skin, and patches 

 of vitiligo. Case 19 was that of a woman of 40 in whom the fingers and 

 toes easily fell asleep and got cold, white and waxy in the winter. 



Case 7 was that of a woman in whom the disease began at the meno- 

 pause. 



The reason I mention the above symptoms, which in the light of our 

 present knowledge are referable to a disturbed autonomic nervous system 

 with inclusion of the endocrin glands is that the theory of Remak, Schnee- 

 vogt, Jaccoud, and Dumenil relative to the dependence of the affection on 

 such disturbance of the vegetative system has now been shown to have 

 some foundation. 



The microscopic examination of the muscle fibers in Barsickow's cases 

 showed changes in the muscle fibrils, some of which were much thickened, 

 while between the primitive muscle bundles were many fat cells and con- 

 nective tissue. The skin spots appeared in the neighborhood of recently 

 affected muscles. In three cases with necropsy there was no abnormality 

 of the nervous system demonstrable, and yet the author inclined to the 

 idea that the disease is of a "vasomotor-trophic-nerve character." The 

 Barsickow cases undoubtedly belong to the Erb juvenile and adult types. 



Friedreich's Group. In Friedreich's group of cases the disease was 

 early in appearance, rapidly progressive, and fatal. Friedreich published 

 the cases of four brothers whose mother was unaffected by the disease, but 

 two of whose maternal uncles died of it in their 15th and 16th years. The 

 brothers cited died at 5, 6, 12 and 16 years of age. . Intellectually they 

 were all well advanced. The affection began as weakness of the lumbar 

 muscles, with constantly increasing difficulty in arising from a sitting 

 posture. Muscular atrophy began in the muscles on each side of the spine 

 at the same time. There then arose a difficulty in raising the arms to the 

 shoulders on both sides. One of the victims died of suffocation from an 



