Between one and two above, he had a sudden

The dynamometer shows The patellar tendon or exaggerated and there is left tendon reflex shows

confined to bed for a month and attended by a physician. This attack left him with some suppurative disease of his left eye which gradually destroyed the sight and the eye was enucleated about a year after. years after the attack described paralysis of right arm and leg and right side of the face. He was walking on the pavement outside his house when he suddenly fell and was unable to get up without assistance. There was no loss of consciousness. From his description there must have been a moderate degree of aphasia. He now presents the following rather remarkable array of symptoms; a right hemiplegia involving the face on the same side. This paralysis, according to the history, was for a time absolute. He can now walk with some difficulty and can use his arm a little. The tongue when protruded deviates to the right side. grasp of right hand 75, left 130. reflex on the right side is greatly ankle clonus on this side. The little if any exaggeration and no ankle clonus is present on this side. If the left or non-paralyzed tendon be struck with the percussion hammer there is a movement of abduction of the right or paralyzed leg, the abductor associate reflex. This form of association reflex, it may be said in passing, is not uncommon. The right leg is about half an inch smaller than the left and the same difference exists between the right and left arms. There is no aphasia but his articulation is difficult. The movements of his tongue are good and he experiences no trouble in swallowing. in swallowing. General sensibility is unimpaired except around the left eye and temple. Here there is loss of tactile and pain sense; temperature sense remaining normal. Taste is lost on left side of tongue, and for this reason he chews on the right or paralyzed side, though with some difficulty, since he has but imperfect control over the right buccinator and the movements of the tongue to the right, are performed with difficulty. Careful testing would seem to show that the sense of smell was absent on the left side. With the right nostril closed he was not able to perceive the odor of vale

rian. Examination of the hearing shows nervous deafness in the left ear. Dr. H. H. Friedenwald reports; vision for distance good at 3 feet. Right eye removed for some suppurative disease.

Hemianopsia on right side involving entire side, the lower periphery encroaching on left field. The line of vision runs directly through the fixation point. The pupil reacts about equally whether light is thrown on the right or the left side.

There is no disturbance of the muscular sense and the electric reactions show no qualitative changes. There is a slight quantitative diminution on the right side. There are no sphincter disturbances and no trophic manifestations. other than the slight atrophy on the right side from

non-use.

It is remarkable that the nerve which is so frequently paralyzed in syphilitic nasal disease, the motor occuli has in this instance apparently escaped; nor is there any evidence of paralysis of the fourth or sixth nerves.

To sum up the symptoms, there is a right hemiplegia and right hemianopsia presumably from central disease, with involvment of the right facial nerve, left olfactory nerve, the left auditory nerve, the left trifacial and the left glosso-pharyngeal.

The explanation of this case would seem to be a gummatous leptomengitis, irregular and extensive in outline but mainly on the left side. Following this was a thrombosis of the left middle cerebral artery, accounting for the right hemiplegia. The hemianopsia is either due to involvement of the optic tract or to disease of the cuneous lobe of the left side. It was noted that the pupil reacted equally whether the light was thrown on the right or the left side. Now according to Wernicke this would indicate that the lesion was back of the corpora quadrigemina or in the cuneous. The rule laid down by Wernicke is that when the pupil contracts when light is thrown on either the diseased or the normal side then the lesion is posterior to the corpora quadrigemina. When however contraction of the pupil occurs only when the light strikes the sound side of the retina no

contraction following the light stimulation of the blind side. then the lesion is somewhere between the chiasm and the corpora quadrigemina. It must be said that the observ. ations of Henschen and others, cast considerable doubt upon the accuracy of this symptom. The patient has begun to improve under anti-syphilitic treatment and it is quite possible that the symptoms due to peripheral nerve involve ment may partly or entirely clear up.

The Virile or Bulbo-Cavernous Reflex.*

By PROF. C. H. HUGHES, M. D.

Honorary Member British Medico-Psychological Society: President Section on Neurology. American Medical Association; President of Faculty and Professor of Neurology and Psychiatry, Barnes Medical College, St. Louis, U. S. A.; President of Section

AT

on Nervous Diseases, First Pan-American Medical Congress, etc., etc.

Ta session of the Societe de Biologie, on May 3rd, 1890, M. Onanoff proposed to designate under the name of bulbo-cavernous reflex, the smart contraction of the ischioand bulbo-cavernous muscles (erector penis and accelerator urinae) which mechanical excitation of the glans produces in the normal man.

Clinical researches which he has carried on with regard to this phenomenon have permitted him to establish some considerations of real value as to to prognosis and diagnosis of certain nervous diseases.

For his examination he proceeded in the following manner: The index finger of the left hand being placed upon the region of the bulb of the urethra, the right hand rapidly rubs the dorsal surface of the glans with the edge of a piece of paper, or again lightly pinches the mucous membrane. In these conditions the index finger applied upon the region of the bulb perceives a more or less intense twitch which is in relation with the contraction of the ischioand bulbo-cavernous muscles.

Here are the results M. Onanoff furnished by study of this new sign:

In sixty-two adult subjects regarded as healthy, or at least exempt from all appreciable neuropathy, the bulbocavernous reflex has never been absent.

*Presented by the author in abstract to the International Medical Congress at Moscow August, 1897.

In aged persons who had lost their virility, on the contrary, the reflex in question is abolished or scarcely perceptible.

In three cases of common hemiplegia, where the genital functions were not influenced by the disease, the reflex was normal and without exaggeration.

In two cases of transverse myelitis, situated at the level of the superior lumbar region, the reflex was manifestly exaggerated. In these two cases the erection took place without the knowledge of the patient.

In progressive locomotor ataxia it is to be remarked. first that as a general rule the urinary troubles appear to have no influence on the bulbo-cavernous reflex.

On the other hand, when the reflex exists in these patients, they have preserved intact or exaggerated their sexual function, while when it is abolished they never have complete erections. Nevertheless, it may occur that certain tabetic patients have seen their genital function diminish although they have preserved their reflex. But then the impotence will be transient and the return of the function is the rule under the influence of treatment (suspension). On the contrary, with that same diminution of the genital reflex, we may see that the impotence will be lasting and the treatment ineffectual.

It results that in this category of diseases the presence or the absence of this sign is very important for the prognosis of genital trouble. M. Onanoff adds that it appears to him to be prudent to speak with some reserve by reason of the small number (thirty-four) of his observations on ataxics. In the last place, the same sign may aid in the diagnosis of certain cases of impotence of such difficult pathogeny as we observe in urinary, hemorrhoidal and divers neuropathic patients. In all these cases, in fact, the bulbocavernous reflex is never wanting, and it is habitual that the genital functions re-appear under the influence of the treatment of the principal disease. The author cites in this respect an instructive fact. In diabetis mellitus, with loss of patellar reflex and abolition of genital functions, the bulbocavernous reflex persisted although feeble. Now when the