. A treatise on nervous and mental diseases, for students and practitioners of medicine. y occur when the muscles of mastication are affected. In pronun-ciation difficulty is first noticed in articulating the letter i; then, in thecoursf! of time, r, sh, s, 1, k, g, t, and usually last of all d aud n. This WHS tlie name by wliicii it was first described by Duclienne. 278 NERVOUS DISEASES. Of the muscles of the lip and lower face affected, the orbicularis orisis usually the first; then, in lesser degree, the levators of the upperlip, the quadratus triangularis, levator raenti, and the buccinato
. A treatise on nervous and mental diseases, for students and practitioners of medicine. y occur when the muscles of mastication are affected. In pronun-ciation difficulty is first noticed in articulating the letter i; then, in thecoursf! of time, r, sh, s, 1, k, g, t, and usually last of all d aud n. This WHS tlie name by wliicii it was first described by Duclienne. 278 NERVOUS DISEASES. Of the muscles of the lip and lower face affected, the orbicularis orisis usually the first; then, in lesser degree, the levators of the upperlip, the quadratus triangularis, levator raenti, and the eyelids are not usually affected—indeed, some excellent authori-ties say they never are; but I have had two cases in which there wasparesis of both upper lids. When the lips and lower facial musclesare implicated the expression of the face will undergo an naso-labial folds deepen on each side, so that the patient has awoe-begone look, and the lower face is immobile, contrasting sharplywith the animation given to the upper face by the intact muscles of Fig. Atrophy of the tongue in a case of bulbar j)aralysis. the eyelids. Occasionally atrophy is demonstrable to a certain degreein the lips, but these muscles are normally so thin and small that it isusually difficult to determine this point. The patient finds difficultyin blowing, whistling, puckering the mouth, kissing, etc., and in pro-nouncing the lip-sounds, mainly noticeable with o, u, and a; thenwith p and f, and finally with b, m, and w. The combination ahseems never to be disturbed. Later on the palate becomes affected, andmay be seen to be paretic. The pronunciation is then altered of the band p, which are made to sound like me and we ; this can be remediedmomentarily by closing the nostrils with the fingers. The voice has anasal twang. The laryngeal, respiratory, and cardiac symptoms aredue to implication of the nucleus of the spinal accessory. It must beborne in mind, however, that the spin
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