560 DR JAMES W. DAWSON ON 



speech, and that sometimes she had difficulty in pronouncing words. The menstrual 

 periods had been somewhat irregular, usually occurring too frequently, but lasting 

 only a very short time. As these symptoms became progressively worse, she was 

 sent to the Royal Infirmary, Edinburgh, to be examined by the late Dr Alexander 

 Bruce, who at once admitted her to his ward. 



Previous Illnesses. — Patient had always been remarkably healthy as a girl, 

 and, with the exception of occasional " bilious headaches," can remember of no 

 other illnesses. 



Condition on Admission. — Her appearance was that of a strong healthy girl 

 with a good fresh colour. Smell and taste were normal. The pupils were circular 

 and equal and reacted both to light and to accommodation. The eyes were freely 

 movable in all directions. There was slight lateral nystagmus on looking to the 

 left and slight rotatory nystagmus on looking upwards. Both discs were normal. 



Sensation to touch, heat and cold, and pain was intact ; and there was some 

 tenderness on deep pressure of both calves. 



The knee-jerks were both exaggerated, the left rather more than the right. 

 Both Achilles jerks were also exaggerated, and Babinski's sign was positive on both 

 sides. The abdominal and upper limb reflexes were all present and apparently 

 normal. There was no wasting of any muscles. There was slight inco-ordination 

 in the finger-nose test with the right hand, but no intention tremor and no inco- 

 ordination of the lower limbs. 



The heart was not enlarged, the apex-beat not displaced, and the pulse was 70. 

 There were no murmurs present, and the arteries were not thickened nor the blood 

 pressure raised. 



The chest was well formed and the expansion good. Neither percussion nor 

 auscultation revealed anything abnormal. 



There was no enlargement of the liver or spleen. The stomach was not dilated, 

 the digestion was good, but there was considerable constipation. The urine contained 

 neither albumen, sugar, bile, nor pus, the specific gravity being 1017. She has 

 occasional attacks of precipitate micturition. 



Progress. — She was put to bed and at first made good progress, but on 25th May 

 numbness in the left arm developed suddenly. On the 29th she felt deaf in the 

 right ear, with dull buzzing sounds, and noticed that her right eye watered 

 exceedingly. She complained of feeling her face squint on speaking. On 

 examination a right facial paralysis was found. The right eyelid scarcely moved on 

 attempting to close the eye. The electrical reactions on the affected side of the face 

 were normal both to Faradism and to galvanic stimulation. On the 3rd of June 

 she developed diplopia on looking to the right, and was found to have a paralysis of 

 her right external rectus. The other movements of the right eye were normal, and 

 the left eye was unaffected. The pupils were equal, rounded, and dilated, and 

 reacted to Light and to accommodation sharply. Five days later the tongue was seen 



