UPON TRANSFERRED PATELLAR TENDON- 
REFLEX. J 
Bv ALLAN McLANE HAMILTON. M.D. 
OUR attention is sometimes directed to anomalous 
cases of disease of the nervous system in which 
the so-called transfer symptoms exist. In those examples, 
when associated movements which are so common in 
various phases of pyramidal degeneration are present, 
the pathological explanation may lie in a cerebral or spinal 
commissural arrangement. 
In alluding to the existence of reflex excitement in con- 
nection with lateral-column disease, Ross and others call 
attention to certain crossed-reflexes which are evoked when 
the periosteum or fasciae are the initial points of shock. In 
1873 I pointed out the fact that in irregular posterior spinal 
sclerosis it was possible by galvanization of the quadriceps 
of one extremity to produce contraction of the muscle in 
the other. Since that time various observers have noticed 
the same phenomenon, and the transfer of reflexes, not only 
in posterior spinal sclerosis, but in other diseases, has come 
to be accepted as a clinical fact. The following history 
is one which demonstrates a much more interesting phase 
of reflex activity than any I have seen, and I think it proves 
that in certain cases there is a direct and limited crossing of 
centripetal impulses in the cord. 
L. J., aged 48, is a man of good habits, yet a rather free liver. 
His family history discloses no nervous disease, and there is no 
Reprinted from the foil etui ?p Nakvous Mental Disease, Vol. 
x. No. 4, October, 1883. "X ~ 2 
TRANSFERRED PATELLAR TENDON-REFLEX. 
reason to suspect syphilis. He has led an active life and done 
much hard work. About four years ago he began to manifest the 
symptoms of his present malady. He was restless, irritable, and 
at times melancholic and depressed. He was rather boastful, yet 
his extravagant talk was not that of dementia paralytica, and had 
some basis. About this time he found that the right upper ex- 
tremity was weaker than the left, and that it became agitated by 
tremor which increased when he attempted some complex act. 
Subsequently the left upper extremity was affected in the same 
way, and then the legs in turn became weaker and he was obliged 
to discontiuue his daily horseback exercise and his walks, and only 
left his house when obliged to do so. He had some pains in the 
lower extremities, mainly confined to the nerve-trunks, but there 
was no anaesthesia. 
I saw him in April last and he has since been under my care. 
In appearance he presents the facies of Parkinson’s disease, and 
his eyes have an anxious and sorrowful expression. Facial inner- 
vation is weak, and fibrillary twitchings, especially of the muscles 
about the mouth—the orbicularis and levator anguli oris, are 
quite decided when he attempts to speak. His tongue is the seat 
of a coarse tremor, with convulsive retraction of the whole organ 
when it is protruded. His speech is “scanning” and somewhat 
explosive at times, and labial and lingual articulation is decidedly 
at fault. Both optic disks show commencing gray-atrophy, but 
there are no evidences of paresis of the muscles of the eyeball, 
and no hemiopia. The right pupil is larger than the left. He 
sits with head bowed and body curved. 
There seems to be a general tremulous condition of the entire 
frame when at rest, and as well, a marked voluntary tremor. This 
is increased when he is excited. His walk is unsteady and 
feeble, his feet are somewhat separated, and he sways to 
and fro when progressing, and seems to be impelled forward ; 
in fact, there is conspicuous festination. The muscles respond, 
if any thing, rather too actively to both currents, when directly 
or indirectly applied, and the electric sensibility seems unaffected. 
He has a rather active expulsion of urine, but beyond slight con- 
stipation his bowels are unaffected. His general physical con- 
dition is as good as it could well be. Mentally he is disposed to 
be boastful regarding his professional career and income. The 
burden of his conversation is about the value of his jewelry and 
pictures, the extent of his business, and his elation suggests dis- ALLAN Me LANE HAMLLTON. 
3 
ease. He cannot write except with great effort, and his attempts 
result in “ shakiness,” and badly formed words. 
The reflexes are all exaggerated on both sides, and the slightest 
cutaneous or tendinous irritation gives rise to decided motor ex- 
citement. When in a constrained position, or when both feet are 
placed upon a chair, a violent and continued tremor is induced, the 
ankle-clonus is bilateral and violent, and the Achillar-reflex lifts 
each heel quite forcibly. The cremasteric, abdominal, and upper 
reflexes are all pronounced. When his thighs are supported so 
that both legs hang loosely, a very curious phenomenon is wit- 
nessed. I have upon three separate occasions made the test and 
have evoked a limited crossed-reflex ; that is to say, when the 
right patellar tendon was struck a light blow, the opposite leg 
would present the jerk, and the left foot would be thrown 
out. When the left patellar tendon was tapped, the result 
would be reversed. There would be no jerk upon the side struck, 
but the muscular action would invariably follow in the other limb. 
I was at first disposed to look upon this peculiarity as a chance 
expression, or perhaps an associated contraction, but its con- 
stancy, and the fact that the muscles of the excited side did not 
respond, convinced me of the curious and extraordinary nature of 
the symptom. None of the other reflexes were transferred. 
Ross,1 as I have said, speaks of certain “ periosteal ” and 
“ fascial ” reflexes, and refers to the results he has obtained 
by tapping the middle of the tibia, and other like sites, 
when ensuing contraction of the quadriceps upon the same 
or opposite side, as well as of the adductors, would follow 
when the legs were extended. Though closely resembling 
the motor disturbance in my patient, I do not believe these 
examples come under the head of true transferred reflexes 
such as are presented in the case of L. J. In him the pa- 
tellar tendon was stretched and struck fairly with the 
rubber hammer so that no diffused jarring resulted, as might 
have occurred had the patient been extended upon a bed. 
The fact of the uniform crossed-results points to the cer- 
tainty of a primary localized peripheral irritation of the cen- 
tripetal conductor, and a secondary stimulation of a motor 
1 “ The Diseases of the Nervous System,” vol. i, p. 153. 4 
TRANSFERRED PATELLAR TENDON-REFLEX. 
centre in the opposite side of the cord. In his case there 
were no crossed “ periosteal ” or “ fascial ” reflexes, and, no 
true transferred tendinous reflexes in any other part of the 
body. 
AC, AC, cells of anterior horns. M, M, motor conductors. I, I, inhibitory 
centres. PD, PD, degenerated pyramidal columns. S, S, posterior fibres ter- 
minating in skin. DT, DT, direct tendinous fibres. CT, CT, commissural 
tendinous fibres. 
Whether the transfer of the excitation in this case is due 
to some anomalous anatomical arrangement of the sensory 
fibres of the cord, or to some unusual location of the lesion, 
I am unable to say. I believe, however, that other examples 
may be found when the tests are uniformly made. Here_ 
tofore most observers have tested the patellar-reflex by 
making the patient cross his legs; or one extremity has ALLAN McLANE HAMILTON. 
5 
been tested at a time. If both legs are suspended, it is pos- 
sible that transferred reflexes may be detected, more fre- 
quently than they now are, and I have had constructed, for 
the purpose of determining the absence or presence of the 
patellar tendinous reflex, a small support of T shape, with 
a firm base, upon which both thighs may be placed. This 
is a convenient apparatus in many ways, and of great ser- 
vice when the patient happens to be a corpulent person. 
It is very probable that more fibres of the external fas- 
ciculi of the posterior nerve-roots pass forward and decus- 
sate than we have any idea of; or that the internal group of 
large motor cells receives sensory connecting fibres, which 
may sometimes be in excess of the direct fibres. Whether 
L. J. always presented the crossed-reflex in health is not 
known. It may be assumed, however, that either through 
disease of the direct centripetal sensory fibres in that part of 
the cord from which the second, third, and fourth lumbar 
nerves arise, or an anomalous development of the crossed 
fibres, the peripheral stimulation is carried across the cord, 
and as the inhibitory influence coming from both lateral 
columns is abolished, the motor discharge may proceed 
from the cells in either anterior horn. The accompanying 
plate is intended to show the course of the commissural 
fibres of the external fasciculi and their cell-connections.