can be found than what obtains in tumors of the frontal lobes of the brain. The difficulties of localization in such cases may prove well-nigh insurmountable, so that unilateral exaggeration of the knee-jerk or the appearance of ankle clonus on one side is welcomed. Of similar significance is the appearance of the extensor of the plantar reflex, or, as my colleague, Dr. Grainger Stewart, has shown, diminution or abolition of the superficial abdominal reflexes on the side opposite to that on which the tumor is situated.

Another class of case in which the reflexes may prove helpful is that in which the question to be decided is whether the disease is in the cerebellum or pons. The determination of this point becomes particularly important when a tumor is responsible for the symptoms, for, while those which occupy the pons are inoperable, no more successful class of intracranial tumor is met with from this standpoint than many of those which involve the cerebellum. They supply us with some of the most brilliant results of modern surgery. While there are many points on which the diagnosis must rest, it is not too much to claim for the reflexes that they play an important part in deciding the question at issue, for the earlier they become affected in the clinical history of the case, the more likely is the tumor to be situated in the pons, while the longer they remain unaltered the greater is the likelihood that the seat is the cerebellum. The knee-jerks cannot be said to be of material assistance in this connection, for, as already noted, they may become altered in uncomplicated cases of tumor of the cerebellum. It is, however, otherwise as regards ankle-clonus, and alterations of the superficial reflexes, for unilateral diminution or abolition of the abdominal reflexes, or alteration of the plantar reflexes to the extensor type, cannot be regarded otherwise than of importance in diagnosis, if they are determined sufficiently early in the clinical course of the patient's illness to make it improbable that they are the outcome of some complication rather than due to the original malady.

4. THE EXTENT AND SEVERITY OF THE MISCHIEF.

It would appear to be self-evident that, inasmuch as the various reflexes have different segments of the spinal cord on whose integrity they depend, the fewer that are lost the less extensive the lesions, and the wider the extent of their affection, but more widespread the distribution of the morbid process. It must be clearly recognized, however, that this is by no means necessarily the case, for, in reality, this only applies in some instances, for a very limited lesion may give rise to widespread alterations of the reflexes. Take, for example, a case in which the lesion is limited to the cervical region of the cord, and abolishes the scapulo-humeral and other arm reflexes. Many other reflexes will also be altered, though not necessarily abolished, so that among the abnormal phe

nomena to be looked for are exaggeration of the knee-jerks, ankle clonus, and the extensor type of plantar reflex.

No better example of the value of the reflexes in determining the severity of a lesion can be suggested than is supplied by the knee-jerks in cases of transverse lesions of the spinal cord above the lumbar enlargement, for when, instead of being exaggerated, they are abolished and remain absent, the gravest fears are justified. When the knee-jerks do not return there is every reason to fear a severence of the cord so complete as to preclude the possibility of re-establishment of the paths through the damaged segments of the cord. Ankle clonus, a phenomenon that we view with concern under other conditions, would now be welcomed, as this would indicate possibilities of recovery which would not have been justified had the knee and ankle-jerks remained absent.

5. LIMITATIONS TO THE VALUE OF THE REFLEXES.

There are instances in which the reflexes only partly clear up the diagnostic problem. Take, for example, a case of myelitis with paraplegia as the result. From the reflexes alone the diagnosis may be made as to whether ordinary myelitis or polio-myelitis exists, but further than this they cannot take us. The X-rays may reveal tuberculous disease of the bone, which has not as yet produced spinal deformity, or the opsonic index may raise the suspicion of a tuberculous origin of the paraplegia in a way that is impossible to the reflexes.

Similarly, syphilitic pachymeningitis may not as yet have occasioned any alteration in the reflexes by which an organic condition can be diagnosed, and yet lumbar puncture may permit the determination of leucocytosis that allows a positive diagnosis to be made. Or the behavior of the superficial reflexes may justify the diagnosis of an organic hemiplegia, while it requires the ophthalmoscope to say that a tumor is responsible for it, or lumbar puncture to indicate that the thrombosis which underlies it is of syphilitic origin.

Furthermore, it must be remembered that there are some affections of the nervous system in which a diagnosis is to be made without any necessary assistance from the reflexes. Chorea supplies an example, for, although in this affection the special alteration of the knee-jerks, to which Gordon, of Exeter, called attention, may be present, in which the limb remains suspended in mid-air too long in response to a blow on the patella tendon, the diagnosis has to be made without any such assistance from the reflexes in the majority of cases. The extensor of the response, and special alteration of the superficial reflexes to which Babinski called attention, are too infrequent to justify any reliance being placed on them.

The fact must not be lost sight of in this connection that the negative may be of little less value than the positive in some cases,

and that, accordingly, there are instances when the fact that the reflexes are not affected in a case proves almost as helpful as if they were, for this serves to distinguish the malady from one in which alterations of the reflexes were to be expected.

6. THE PART THEY PLAY IN THE DIAGNOSIS OF GENERAL DISEASES.

The question that next arises is as to whether the reflexes give any assistance in diagnosis in realms outside those of neurology. There can be no doubt that there are many cases in which, in the absence of any known disease of the nervous system, the reflexes are altered in the course of some general disease or special affection of some other organ of the body.

It will be remembered that in an affection like diphtheria absent knee-jerks may give the first clue to the nature of a sore throat that ought to have been long since determined by bacteriological examination of secretion from the fauces. Similarly, absence of the knee-jerks may call attention to the possibility of glycosuria, which routine examination of the urine should have forestalled.

Some attempt has been made to derive direct advantage from alterations of the reflexes as in favor of one as opposed to another disease in which the nervous system plays no part, except that the toxins of the one malady have a more profound effect on the nerve centres, and occasions alterations of the reflexes in consequence, in a manner that does not obtain in the other disease. Thus, the kneejerks have been found absent in a large proportion of cases of pneumonia due to the diplococcus or the diphtheria organism, while they are not affected in septic pneumonia and found exaggerated in tuberculous cases (Stanley Barnes.)

The chief value, however, that attaches to these observations in the present state of our knowledge is that they prevent us from concluding that some organic condition, as, for instance, myelitis or meningitis, has of necessity developed because these alterations in the reflexes are determined. Those interested in the welfare of the patient are thus spared the anxiety that would be caused by the opinion that might have been expressed in ignorance of the fact that the alterations noted are compatible with transitory effects due to toxic conditions without any permanent organic change.

In conclusion, Mr. President, ladies and gentlemen, let me thank you most sincerely for the patient hearing you have given me. No one is more conscious of the shortcomings of this address than I am. I wish it had been possible for me to prove more worthy of the trust that has been placed in me, and the honor which that trust implies. I can only take comfort in the fact that I have spared no pains to make the address a success, so that any failure to do so cannot be ascribed to a lack of appreciation of the great responsibility which I have accepted, and of which I have been only too

painfully conscious. One other consideration brings me comfort in my ordeal; that is, that I am in the midst of friends who will deal leniently with my shortcomings. In his letter of invitation your worthy Secretary, Dr. Hacking, told me that I would meet many friends who would be ready to welcome me to Canada. I have, indeed, met with friends, and have been overwhelmed with kindness. Let me take this opportunity of thanking you all most cordially for the welcome you have so generously extended to me.

• Selected Articles.

THE FUTURE SCIENCE OF MEDICINE.

BY J. MADISON TAYLOR, A.B., M.D., PHILADELPHIA.

UNDER the above heading the St. Louis Medical Review of June 8, 1907, published the following lines: "Dr. C. E. de M. Sajous announced on June 3rd, at the American Medical Editors' Association, the crowning point of his patient labors on the ductless glands, in the discovery in the pituitary body of a membrane functionally resembling the Schneiderian (its olfactory area), in that it tested the condition of the body fluids and automatically regulated the correction of depraved conditions by producing antitoxins. Complete details by the author will appear shortly. It seems probable that an absolutely scientific therapy is now within sight." The announcement referred to was made at the dinner of the Association, which took place on the day mentioned. The complete details are to be found in the second volume of Sajous's Internal Secretions," which has since appeared. The great interest awakened by his address, and the recent announcement that "Internal Secretions" was regarded on the Continent of Europe as so marked an advance in our knowledge of the functions of the ductless glands that it is to be translated into French by one of the greatest authorities on the anatomy and histology of these organs, Professor Launois, of Paris, who has suggested the advisability of giving our readers an outline of the function referred to above, which will unquestionably revolutionize medicine in the sense specified by the St. Louis Medical Review.

As is now generally known, Sajous's study of the functions of the ductless glands was only an incidental feature of his purpose to give medicine a more solid foundation than that upon which it rests at the present time. Nearly twenty years ago, when, as editor of the Annual of the Universal Medical Sciences, it became his duty to collate yearly the progress in all branches of medicine, he was surprised to note the amount of theorizing being indulged in by investigators in every branch of medical science: physiologists, physiologic chemists, histologists, therapentists, clinicians, etc. After reciting a few experiments on