in rare cases affected. Tedeschi found complete blindness with optic atrophy in the left eye of a chronic case and Wickman demonstrated optic neuritis in a recent case. Ed. Müller, however, found the fundus always quite normal.
As observed by Medin, Wickman, J. Hoffmann, Lindner and Mally, implication of the trigeminal may cause a paralysis of the jaw muscles.
The ninth, tenth and eleventh nerves may also be affected. In several, mostly fatal, cases difficulty in swallowing was present, but isolated paralysis of the pharynx has also appeared in a few cases. Wickman recorded as the only symptom in one case, a unilateral paralysis of the velum palati. If the palsy is incomplete, the injury to the muscular apparatus may still be recognized from the striking tendency of the patient to swallow "the wrong way."
Involvement of the laryngeal muscles may produce hoarseness or aphonia (Medin, Huet, Wickman, J. Hoffmann). Respiratory disturbances may depend upon either an affection of the center for the intercostal muscles or a lesion of the nucleus of the vagus. It is sometimes impossible to distinguish the precise origin of the disturbance. One kind of respiratory disturbance, which in all probability is due to involvement of the vagus, is the spells of respiratory difficulty described by Wickman and Medin; tachycardia accompanies these spells.
Cheyne-Stokes' respiration, which has been observed in a few cases, is certainly due to an affection of the respiratory center. I have already mentioned a case in which the accessorius almost alone was involved. During the epidemic in Sweden, in 1905, paralysis localized to the neck muscles was noted in a few cases. Besides these paralyses of cranial nerves, the bulbar type of Heine-Medin's disease sometimes presents symptoms which arise from implication of nerve tracts which merely pass through the brain stem or bulb. Wickman described such cases; in one, besides paralysis of the eye muscles and of the left side of the face and right side of the tongue, cerebellar ataxia was present; another showed paralysis of the left facial and hypoglossal, slight scanning, syllable-stumbling speech, some ataxia of the arms and exaggeration of the deep reflexes of the legs. Zappert and Spieler enumerate analogous cases. J. Hoffmann observed in two cases
