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FROM T H E Nl3l'ROLOGICAL S E C T I O S O F S T A T E HOSPITAL, OSLO,

S O R W A Y . P R I N C I P A L : PROFESSOR G . H . M O N R A D - K R O H S . M . D .

REFLEXES O F S P I N A L AUTOMATISM
nY

AXEL 0WRE

The reflexes of spinal automatism, reflexes which occur when


the spinal cord is liberated to a greater or lesser degree from
cerebral control, are more or less constant and typical reflex
movements which may be elicited by affections of the pyramidal
tracts and especially by stimuli which cause a sensation of
pain in the normal organism. These reflexes manifest them-
selves in their typical form as synergies of flexion and exten-
sion,, i. e. not a simple movement as in the case of tendon and
cutaneous reflexes but a complex and approximately co-
ordinate movement of the extremities.
The most constant and typical of these reflexes is the flexion
reflex which consists of a flexion in the hip and knee joints
and dorsal motion in the ankle and big toe joints, followed by
slower extension. Under certain definite conditions this reflex
is accompanieed by an extension movement in the other leg.
This reflex is what is called crossed extension reflex.

METHODS O F INVESTIGATION
The neurological routine examination, including motility,
co-ordination, sensation, tendon and cutaneous reflexes, gives
no certain information with regard to reflexes of spinal
automatism. When the inverted plantar reflex is observed the
reflexes of spinal automatism are as a rule present.
Normal individuals who are subjected to painful irritation of
the sole of the foot withdraw the leg involuntarily; that is to
say, they perform a flexion which may possibly mislead an
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untrained observer, the only distinctive physiological indication
- apart from speed, extent and character - being a plantar
motion of the big toe while this motion is dorsal in the
pathological condition. There is, however, a sure distinction,
as a dorsal mofion in the ankle joint brought about by stimuli
not applied to the sole of the foot warrants the assumption of
a diseased condition (Babinski).
a. Nature of Stimuli. The stimuli adequate to elicit reflexes
of spinal automatism are all kinds of irritation which cause a
sense of pain in the normal organism. Pricking, stroking or
scratching with a pin, pinching, cold and hot water and faradic
currents are the means of irritation employed.
The receptive field of reflexes of spinal automatism includes
all the layers of tissue, and these reflexes ma y be elicited not
only by application of stimuli to the skin but also to joints,
tendons, muscles, periosteum an d bones.
There are several methods of irritation which various
investigators have maintained to be the most expedient. Thus
Marie and Foix employ either a plantar motion of the toes
which are held in the hand and bent rather brusquely in the
plantar direction or they squeeze the blade of the foot over the
metatarsal bones i. e. exercise a transversal pressure on the
foot. Both these methods give good reflex responses, but the
first method conceals the movements of the toes a n d the field
of irritation is rather extended. Babinski recommends pinch-
ing of the skin as the best method of irritation. In this connec-
tion the reflex dorsal motion of the big toe observed by Schaf-
fer, Oppenheim an d Gordon by pinching of the Achilles tendon,
frontal pressure of the tibia and pinching of the muscles of
the leg below the knee may be called to mind. These methods
of irritation also give flexion reflex.
The Writer has found that pinching of the skin with the
fingers or with pincers and pricking or stroking with a pin are
the most expedient methods of irritation in the great majority
of cases. I n the course of the present examinations all the
above mentioned methods of irritation have been employd, but
careful observations have shown that even the faradic current,
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which is so much favoured by many because the stimulus can


be graduated, must give way to the far simpler method of
pricking, stroking and pinching. Armed with a safety-pin one
is thus fully equipped for the examination of reflexes of spinal
automatism.
b. Intensity of Stimuli and Reflex Irritability. No hard and
fast rule can be laid down for the intensity of irritation neces-
sary to provoke reflexes. It may, however, in general be said
that the stronger the stimulus the greater will be the reflex
both in power and amplitude. The interval which elapses
between the application of the stimulus and the manifestation
of the reflex seems also to be in 'direct proportion to the
intensity of the stimulus.
Stimuli which in themselves are not sufficient to produce
any response may prove to be sufficient upon repetition. Thus,
for instance, a single pin prick may be ineffectual while a
series of five consecutive pin pricks of uniform intensity may
cause the reflex to take place. It will, therefore, often be found
that stroking with a pin is more effective than pricking. In
physiology this is called summation of stimuli.
The intensity of the stimulus must be adjusted to the aim in
view. Thus, for instance, when investigating the limits of the
zone of a reflex, strong stimulus is indicated. Rut when analys-
ing the nature of reflexes, slight stimulus. There is, however,
one thing which determines the required intensity of stimulus,
and that is the reflex irritability, which can vary within wide
limits - at times almost incredibly.
The reason for the variations of reflex irritability is to be
sought particularly in the condition of the spinal cord. In
compression processes and multiple sclerosis excessive reflex
irritability is often found. Babinski assumes that this increased
reflex irritability must be ascribed to intramedullary changes
in such cases.
The general condition of the patient also has an influence
on the reflex irritability. Thus the degree of susceptibility .will
be found to be reduced - in the majority of cases - when the
patient is suffering from bed-sores, affections of the urinary
system, pneumonia or a n y form of toxicosis. Moreover, it may
be mentioned that after traumatic and other sudden lesions
of the spinal cord a condition of suspended reflex irritability
intervenes, called shock.
c. T h e Reflex Zone. Here and elsewhere it is assumed that the
reflex arc is intact, i.e. the affection lies above the spinal centres
of the lower extremities. Let it at once be established that the
sole of the foot, that is, its lateral side, forms the primary field
of application of stimuli for producing the reflexes of spinal
automatism. Next to this comes the dorsal aspect of the foot
a n d the lower third of the leg below the knee. In some cases,
as for instance in a case of hemiplegia, the reflex zone does
not extend any higher, but in other cases, as for instance in
cases of complete transverse lesion of the spinal cord in the
reflex stage,the zone may extend over the abdomen and even the
thorax. In cases where the reflex zone extends over the abdomen
excitability will not be uniform in areas beyond the sole of the
foot. As a rule it may be said that the inner side of the leg,
above an>d below the knee, and the perineum farm the most
easily excitable fields where stimuli of relatively slight
intensily will elicit reflex action. I n all my cases in which the
reflex zone extended over the abdomen it was far easier to
produce the reflexes from the medial side than from the lateral
side of the extremities.
Riddoch’s statement with regard to the reflex zone does not
seem to stand critical investigation. He states that above the
knee the inner side of the leg is the most excitable field and
below the knee the outer side. I cannot agree with him in this
as far as the leg below the knee is concerned, nor in his state-
ment that a small reflex zone, practically limited to the foot
and extending upwards to the knee is characteristic of
imcomplete transverse lesion.
Treshold of irritation is often found to be less on the inner sid-.
of the leg above the knee than below, and on the inner side i &is
always less than on the outer. In the case of the abdomen it
is usually neccessaiy to employ intense irritation in order to
produce reflex action. In those of my cases in which the reflex
zone came to a n end on the abdomen the boundary was, how-
ever, very sharp and the irritation employed was of medium
intensity. The upper limits of the reflex zone may in some
cases indicate the lower limits of the spinal affection. In carry-
ing out this investigation one should remember that the stimuli
must be carefully adjusted and a sufficiently intense stimulus
must be employed.
The reflex zone may be said to be parallel to the reflex
irritability; when the latter is great one will as a rule find an
extensive reflex zone. This parallelism is also observable in
cases of shock, septic conditions and marasmus, both the
reflex zone and reflex irritability decreasing under such con-
ditions. This corresponds closely to what may be found in
medical literature with regard to the gradual decrease and
final confinement of the reflex zone to the sole of the foot in
patients who are approaching death and fall into coma. Two
of my patients died during the examination and in both cases
the reflex zone was not very limited a few hours before death
occurred. In one of these cases the reflex zone was unaltered
four hours before death and in the other case reflex jerks could
be produced from the abdomen twelve hours prior to death.
Thus the last phase in which the reflex zone becomes limited
to the sole of the foot must at any rate in some cases be
counted in hours. In the first case the patient was moreover
in a state of high fever, but in spite of this the reflex zone was
extensive and the reflex irritability very marked. On the other
hand, in cases of shock the reflex zone is, to begin with,
confined to the sole of the foot but it spreads upwards little
by little as the patient passes from the shock stage to the
reflex stage.
d. T h e Position of the Exfemities during Investigation. The
method of procedure is to let the patient lie nude with the
genitals covered and all the bedclothes removed. Care should
be taken that there is plenty of space between the foot of the
bed and the patient’s feel, so that the latter may not strike
the former when extensor response occurs. It is also essential
that the surface on which the patient lies be hard and smooth:
even then the heels will rub against the surface of the bed and
in many cases this is more than enough to elicit reflexes. I n
order to avoid all sources of error I have to a certain extent
examined my patients in a bath. A big bath should be used
and the temperature of the water should be 37O C. The patients
head should rest on a strap and his hands should rest on the
sides of the bath. The patient will thus be kept floating in the
bath and no disturbing influences will affect the reflex action.
This method of examination is - even if a little troublesome
- all the more favourable because the chilling of the
extremities will often lead to the spontaneous reflex movement
taking the upper hand entirely. Moreover one avoids the other
chief source of error, viz., rubbing against the surface of the
bed. In this manner I have been able to establish the fact that
examination made on a bed corresponds essentially with
examination ma,de in a bath, although the latter method has
furnished special information to which further reference will
be made. I will here confine myself to stating that examination
on a bed gives sufficiently reliable results for clinical require-
ments.

REFLEXES OF SPINAL AUTOMATISM


a. Flexion Reflex. If the sole of the foot - the leg being
extended - is subjected to sufficiently intense irritation a
globall) flexor movement of the extremity will be obtained.
This movement consists of dorsiflexion of the big toe and ankle
joints, and a flexion in the knee and hip joints.
The flexion of the hip joint is accompanied by adductional or
abductional movement. This phase of flexion is maintained as
long as the irritation lasts and it is followed after a more or
less protracted space of time by an extensor phase which
develops more slowly than the flexor phase. The movement
will be rapid or slow according to the tonus and reflex
irritability. When the tonus is not very pronounced and the
degree of reflex irritability high, as for instance in the case
1) The expression ~gIobali( indicates that all the groups of muscles
in the limb take part in the reaction.
of complete transverse lesion, the flexor movement is very
rapid while the extensor h a s the character of a passive, gravita-
tional movement. Riddoch has therefore distinguished between
uniphase and biphase flexion reflexes. This distinction seemr
to m e to be superfluous. In one of m y cases it was difficult to
decide by examination on a bed whether it was a case of
.uniphasecc or >>biphasec(flexion reflex. Examination in a bath
showed, however, that the extensor phase was just a s active a s
the flexor. Partly because doubt may be raised a s to the
existence of the uniphase flexion reflex and partly because it
has little or no independent significance here the terms
uniphase and biphase have not been adopted. Hereinafter
flexion reflex is assumed to include both the flexor and the
extensor phases.
The scope of the reflex actions will depend on the intensity
of the stimuli and the reflex irritability. A very slight irrita-
tion of the sole of the foot will produce a single reflex action
- a dorsiflexion of the big toe. At the same time a tonicizing
acfien on the flexors of tlhe thigh, including tensor fasciaj lataj,
may often be seen and felt. If the stimulus is increased slightly
a dorsiflexion of the ankle joint will also occur and one may
observe a distinct tonicizing action on the flexors of the thigh,
while if the stimulus be still further increased the whole reflex
action takes place.
If in the course of the examination one proceeds irom the
sole to the dorsal aspect of the foot and further up the leg, it
will be observed that the dorsiflexion of the big toe and ankle
is maintained a s a n integral part of the flexion reflex until the
thigh is reached. Here - provided the stimulus employed is
correctly adjusted - one will observe that the reflex action
changes in character. Generally flexion of the knee and hip
joints will be the most prominent features of the reflex action.
This essentially local response to irritation is called >>thelocal
sign(( by Sherrington. This form of reaction will also generally
be the most prominent in the case of irritation of the abdominal
area. Even though the flexion of the knee and hip joints is the
predominant feature, a dorsiflexion of the ankle joint will
generally also take part in the reaction, but it will be morr
vague than when the reflex is produced by irritation of the
foot or leg. The toe movement will manifeest even greater
variations. Frequently at the limits of the reflex zone and also
within this zone I have observed plantar motion of the ankle
a nd big toe joints simultaneously with flexion of the hip and
knee joints. This phenomenon h as also been observed by
Babinski, but is not admitted by Walshe.
When irritation is applied to the foot anfd leg below the knee
a dorsal motion of the big toe is a n integral part of the flexion
reflex i. e. one should be justilied in concluding that flexion
reflex is to be considered a true sign of lesion of the pyramidal
tract. Moreover, irritation applied to the thigh and abdominal
area produces a modified reflex action, and it is at all events
not rare that this admits of a break in the flexor synergy, viz.,
a plantar motion of the big toe an d ankle joints simultaneously
with a flexion of the knee and hip joints.
However, the coeditions are not always as simple a s indicated
above. In cases of traumatic complete transverse lesion several
observers have shown that the first reflex movement that can
be elicited when the symptoms of shock have disappeared is a
plantar motion of the big toe caused by irritation of the sole
of the foot. This reaction distinguishes itself very markedly by
its sluggishness and general character from the normal plantar
reflex. (Gordon Holmes, Riddoch, Babinski, Lhermitfe, Guil-
lain and Barre!).
b. T h e Crossed Extension Reflex. This is not a n independent
reflex, but a reflex movement which is closely associated with
the flexion reflex and it must therefore only be looked upon a s
part of that. The crossed phenomenon is also less powerful than
the one-sided and the crossed extension reflex does not take
place everywhere where flexion reflex can be produced.
With one leg slightly bent, the other stretched, the sole of
the foot of the latter is subjected to irritation, producing a one-
sided flexion reflex an d a crossed extension reflex, i. e., a
complicated co-ordinate movement which has the same
character a s the action of walking.
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The crossed extension reflex is especially well marked in


cases of spastic paresis in which increased muscular tonus and
tendon reflexes have been found to be prominent symptoms in
the establishment of the neurological status. Thus it is
especially in paraplegia and hemiplegia in extension (the
reflexes being elicited from the unaffected side) that this reflex
phenomenon appears.
Walshe and Riddoch both maintain that the reflexogenous
zone of the flexion reflex and the crossed extension reflex are
identical. I cannot agree with this. The reflexogenous zone of\
the crossed extension reflex is more closely connected with the
distal parts of the contralateral extremity and in my examina-
tions at all events it has been found difficult to elicit this from
the thigh and abdomen. In the cases in which this was possible,
the reaction was not very characteristic. As it is of small
importance in clinical practice to be familiar with this reflex
zone I would recommend that in examining it the stimulus be
applied to the sole of the foot, and that the intensity of the
stimulus should be somewhat energetic. Moreover, care must
be taken to be certain that the passive, slightly flexed extremity
has come to a state of rest, as one may otherwise fall a victim
to false conclusions. The flexed extremity may very well be
turned outward resting halfway on the surface of the bed.
As will be mentioned later on, the extensor tonus is assumed
to be associated with special extra-pyramidal or so-called
postural tracts coming from the mesencephalon. A priori, one
would therefore suppose that the crossed extension reflex could
not be produced in cases of complete transverse lesion. As a
rule this is the case, but both Riddoch and Lhermitte refer
without doubt to crossed extension reflex in cases of complete
transverse lesion. Under such conditions one will, however, far
more often find crossed flexion reflex.
c. Rare or atypical Reflexes. The examinations have pro-
duced nothing beyond what is already known with regard to
rare or atypical reflexes: extensor thrust, rebound phenomenon,
reflex stepping, ,Mass-reflexcc and ,,local signs((.
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TONUS
Under normal conditions it is supposed that the pyramidal
tracts from the cerebral cortex and the extra-pyramidal tracts
from corpus striatum convey to the muscular system a tonus-
subduing influence. A weakening or cessation of the functions
of these tracts will therefore result in an increase of tonus (cf.
hemiplegia, paralysis agitans). It is moreover supposed that,
under normal conditions, a tonus-increasing influence comes
from the cerebellum and the labyrinth as well as Prom the
periphery through the posterior roots. In cases of affections
influencing these tracts hypotonia or atony will result (cf. tabes
dorsalis).
Sherrington has proved that the reflex system which main-
tains the postural tonus, i. e., the tonus of the erect position, is
composed of a series of reflex arcs, spinal and prespinal. The
prespinal centres are generally situated in the mid-brain and
their activity is supported by influences from the labyrinth and
the cerebellum. Now the fact is that these prespinal centres
become more and more predominant in relation to the spinal
centres as the upright position and action of walking becomes
more and more customary. In man these centres seem to have
superior functional control and, when the spinal cord is severed,
the ,reflex tonuscc seems to disappear from the extensors of the
extremities. (Sherringfon).
In Sherrington’s opinion the conditions to be considered in
connection with the object we have in view should be as fol-
lows:
In conditions of human disease corresponding to ,decerebrate
rigidity(( (hemiplegia simplex and duplex and other simple
affections of the pyramidal tracts) the prespinal centres will be
intact and, freed from the subduing influence of the pyramidal
tracts, they will bring about a pronounced hypertonia of the
extensors - )>posturaltonuscc - with predominant activity in
these. This corresponds well with the clinical experience, as
increased tendon- jerks, crossed extensor reflex, ,Ph&nomkne
d’allongementcc and extensor thrust are reflex actions to be
observed in these conditions.
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In the conditions of human disease corresponding to ,spinal


animals<<(complete transverse lesion) the extensor tonus should
thus disappear and only reflex actions actuating the flexors
should be producible.
Later study of the complete transverse lesion in man has,
however, shown that tonus and reflex irritability return, after
the stage of shock, to the paralysed muscles, first, and in the
greatest degree, to the muscles of the flexor group, subsequently,
and in a lesser degree, to the muscles of the exteesor group.
Thus tonus in the extensors returns and the degree of recovery
may even be so great that not only the patellar and pedal
reflexes take place, but also patellar and foot clonus. It can
thus be proved that extensor tonus is not so exclusively con-
nected to the extrapyramidal tracts as is postural tonus, and
that tonus is not, as Bastian and H . Jackson believed, only of
cerebral origin. It will therefore be necessary to seek another
solution of the tonus problem.
Mosso was the first to put forward the hypothesis that tonus
depends on both the sympathetic and cerebrospinal nerve
system. Proof of the correctness of this hypothesis was
furnished by de Boer, who found that severance of the sym-
pathetic nerve roots of the lower sciatic nerve in frogs and cats
produces the same decrease of tonus as a severance of the
nerve itself. Further investigations of the dependency of tonus
on the sympathetic nervous system have been carried out by
Botazzi, Buzzard, Pieron and Langelaan.
The striated muscles consist morphologically of two
substances: sarcoplasm and myoplasm.
The plasticity of the muscles seems to be attributable to the
sarcoplasm. This is a more stable component of tonus regulated
by the sympathetic nervous system. It is called plastic tonus.
The contraction of the muscles seems to be attributable to
the myoplasm. This is a more variable component of the t m n s
under the influence of the anterior horn cells of the spinal cord
and is known as contractile tonus.
m e great increase of tonus in cases of incomplete transverse
27 1

lesion of the cord should - at any rate to a certain degree -


be attributable to spasm in the sarcoplasmic element, while
aplasticity or hypoplasticity in complete transverse lesion
should be traceable to rupture between the upper and lower
centres of the sympathetic nervous system. The contractile
element will be present in both cases.
The question now is whether tonus in complete transverse
lesion is ascribable to the sarcoplasm, to the myoplasm or to
both. For the time being this problem cannot be solved. The
uneven distribution of tonus seems to indicate that it cannot
be a plastic tonus only, while the fact that the muscles manifest
an evident resistance to passive movement does not harmonize
with the assumption that it is exclusively a contractile tmus.
For the time being we must satisfy ourselves with the
knowledge that tonus returns and that the muscles of the
flexor group manifest the most pronounced vitality.
If tendon-jerks are viewed in the light of Langelaan’s theory
they can be divided in two tempi: one characterized by a rapid
contraction due to the action of the myoplasm and the other
tonic, showing contraction maintained by the sarcoplasm. This
double action can be plainly demonstrated by severing the
rami communicantes of the lower sympathici, whereby the
tonic phase of the reflexes is caused to disappear while the
phase of contractile tonus is” left intact. In the same way one
may explain both the subsequent prolongation of the patellar
reflex in incomplete transverse lesion and the sudden aplastic
reflex in the complete transverse lesion.
Turning now to a consideration of the reflexes of spinal
automitism it will be remembered that generally speaking these
manifest themselves as synergetic movements: flexion and
extension synergies in which all the groups of muscles in each
class take part in the reaction. In his experimental research’
upon animals Sherrington has shown with all desirable proofs
that when the flexion reflex is produced the function of the
extensors is simujtaneously restricted and vice versa. This is
the law of reciprocal innervation: - antagonistic inhibition in
reflex movements. Hitherto it has been supposed that this law
also applies in connection with the reflexes of spinal
automatism in man.
I will record some clinical observations which indicate that
the conditions are not quite in correspondence with the results
gained by experimental research.
In dealing with the flexion reflex attention has already been
drawn to the fact that breaks in the flexion synergy are often
observable when irritation is applied to the thigh.
Upon investigation of the patellar reflex I have been struck
by the fact (already previously emphasized by Monrad-Krohn)
that the tendons of the thigh flexors sprang forward simul-
taneously with the occurrence of the extensor phase - a result
which in its simplicity must be convincing, this being a
simultaneous extensor and flexor tonus.
Furthermore, I was able in one of my patients to elicit a
))flexion reflexcc which consisted of dorsiflexion of the big toe
and ankle joints, flexion and adduction in the hip, while the
knee was kept extended so that the one leg was thrown over the
other. Here one can hardly speak any longer of ,flexor excita-
tionu or .extensor inhibitioncc, because both phases appeared
simultaneously. This was a constant response to irritation. In
another case irritation of the sole of the foot produced dorsi-
flexion of the big toe and ankle foints and convulsive patellar
clonus, which spread quickly, ending in a tremor of the whole
leg in this position. Now and again this was accompanied by
a sudden flexion reflex.
In lean individuals where the play of the muscles can be
observed and palpated, I have repeatedly been successful in
both seeing and feeling ,,global(( tonus of the muscles of the
extremities. In order to make this observation it is, however,
essential that one should employ stimuli which only just
exceed the threshold of irritation, i. e. stimuli so well adjusted
and slight that one obtains a tonicizing action on the muscles
without any motional reaction. This condition is most easily
demonstrated by applying irritation to the thigh (one must
then of course guard against confusion of jerks in the m. rectus
femoris with extensor reactions, as this muscle acts under
flexion reflex as a flexor of the hip). In the above mentioned
patient with the clonus jerks I was plainly able to observe how
all the mascles of the thigh contracted simultaneously and 1
often received the impression that when I increased the
stimulus it was just as if a struggle took place between the
extensors and the flexors. I also received this impression very
distinctly in cases where I obtained plantar movement in the
ankle and big toe joints simultaneously with flexion in the
hip a nd knee joints. When the stimulus is increased so as to
produce a motional reaction the result is, however, a more or
less typical flexion reflex. Global tonicization seems to be
present in any case quite often when flexion reflex is the ordi-
nary reaction.
One m a y look upon global tonicization as plastic tonicization
and the reflex reactions as contractile tonicization which
accumulates on a plastic tonus already existing (Lungelaan).
With the law of antagonistic inhibition one is enabled to
explain the condition of things referred to above. Using Sher-
ringtons method of expression the stimuli should thus a t one
and the same time find their way on ),the final common path((
both to the muscles of the extensor and flexor group.
Magnus and de Kleijn have shown that alterations take place
in the tonicization of the muscles when the position of the head
is altered. This alteration of tonicization can assumably only
be supposed to present itself in cases of incomplete transverse
affections. In m y cases I could not find that the position of the
head altered the reflex reactions to any essential degree, nor
that various positions of the head could give me any explana-
tion of the conditions of tonicization.
Sherringfon differentiates in his reflex doctrine between
exteroceptive and proprioceptive reflexes, i. e. reflexes caused
by exterior irritation (pain, cold, heat, touch etc.), and reflexes
caused by irritation coming from the extremities themselves
by the stretching of muscles, tendons and joints. The extensor
phase of the flexion reflex may be looked upon as a propriocep-
tive reflex. One may just as well, it appears to me, see in this
19
274
an active expression of plastic tonus, because this will carry
the leg back to a slightly flexed position of rest (cf. examination
in a bath). One might also in support of this view refer to the
sluggishness of the extension phase.

THE CLINICAL SYMPTOMS


The reflexes exist in both cerebral and spinal diseases and
for this reason the division into incomplete and complete
transverse affections is rather unsatisfactory. Nevertheless I
will refer to such cases of disease as transverse affections, as
the resulting phenomenon dependent on the central region will
also be spinal in the second instance. It is absolutely impossible
to present a delineation of the disease in slight, that is to say
incomplete, transverse affections (including the central pyra-
midal affection) and the serious, that is to say complete,
transverse lesions as a clinical symptom-complex presents by
its distinctive nature a picture peculiar to itself, viz., the
paraplegia in flexion. According to the nature of the case,
illnesses as for instance tumors - intramedullary or extrame-
dullary, inflammatory or genuine, myelitis or multiple sclerosis,
may present transition forms from the slightest paraplegia in
extension to the complete transverse lesion in one and the same
patient if he lives long enough.

I. INCOMPLETE TRANSVERSE AFFECTIONS


a. Paraplegia in extension. b. Paraplegia in flexion.
This condition 5s above all Paraplegia in flexion indi-
characterized by the extensor cates a spastic paraplegia
spasm - a stable tonic con- with a stable or more fre-
traction of the lower extremi- quently unstable contracture
ties in extended position. in flexion. In the latter case it
is usually combined with
spontaneous homolateral or
heterolateral, alternating flex-
ion and extension movements,
the flexor action being the
predominant one.
275

Motility: The position of Motility: The position is


the extremities is extended usually extended. One will
with little or no atrophy. often during examination
observe spontaneous one-
sided, double or alternating
flexor movements. (Patients
often describe this as wxamp((
and it is very disturbing).
Atrophy is slight as a rule,
but it may be very strongly
pronounced, especially in
cases where contracture has
become manifest.

Tonus: Palpation shows the Tonus: The muscles feel


muscles to be tense, the ex- tense, the contour of the ex-
tremities having the usual tremities often presents the
contour - the erect oval - erect oval. More or less pro-
more or less, often extremely nounced rigidity, the flexors
pronounced, rigidity, never more rigid than the extensors.
less than the normal. Active movements greatly
Active movement more or weakened. In the most favour-
less retained, never quite ab- able cases the patient can
sent. Often the patient only stand on his legs, ability to
complains of a comparatively walk extremely defective,
quickly appearing feeling of often the patient cannot stand
stiffness. The power of the and active movement may
muscles may be very good, even in a bath be poor.
but it is, however, often re-
duced. Pronounced rigidity is
followed by slow, laborious
and often limited active
mobility.

Sensation: All degrees may Sensation: Varies from great


be manifested, from unaf- deficiency to entire cessation.
fected to greatly affected ones The upper limit of sensation
or complete cessation. corresponds to the lower limit
of the spinal affection.

Reflexes: Tendon and perio- Reflexes: Tendon and perio-


steal reflexes are increased, steal reflexes not seldom in-
the phase of relaxation of the creased generally speaking,
patellar reflex is prolonged. but often reduced in the case
19.
276
of the extensons, while the
tendon reflexes of the flexors
are always increased. The
phase of relaxation of the
patellar reflexes is not seldom
sharp and aplastic.

Cutaneous reflexes: The ab- Cutaneous reflexes: The ab-


dominal reflexes may be dominal reflexes have gene-
normal, weakened or absent. rally completely cealsed. The
The plantar reflex is inverted. plantar reflex is inverted.
Reflexes of spinal auto- Reflexes of spinal auto-
matism: The reflexogenous matism: The reflexogenous
zone is generally confined zone is very extended, reach-
entirely to the extremities, ing often to the abdominal
often not extending farther area. The lower limit of the
than to the knee. The reflex spinal affection may corre-
irritability is not very pro- spond to the upper limit of
nounced. The reflex action is the reflex zone. The reflex
slow and characterized by the irritability is usually very
reflex movements pertaining pronounced. The reflex action
to the extensor system. The is lively, characterized chiefly
usual responses are: flexion by the flexor action: flexion
reflex and crossed extension reflex - often double in
reflex, accompanied occasio- response to one-sided irrita-
nally by ,,ph(.noxn&ne d'al- tion - crossed adductor and
longement((. extensor tonicjzation observ-
Organic reflexes: The func- able, but crossed extension
tion of the bladder is usually reflex rare. Alternating homo-
normal. Not seldom one finds lateral or heterolateral ap-
the symptom called precipi- parently spontaneous reflex
tate micturition, i. e. the pa- movements often disturb the
tient is aware of the com- examination.
mencement of the bladder Organic reflexes: The func-
reflex but has difficulty in tion of the bladder is generally
controlling it. affected. Often precipitate
This is the symptom-com- micturition, not seldom inter-
plex in the great majority of mittent retention of urine.
cases.

If one has an opportunity of observing the development of


an illness transition from paraplegia in extension to paraplegia
in flexion is not rarely seen. A passing disturbance in the con-
dition of the sufferer may present a case of transitory paraplegia
in flexion, i. e. a stable paraplegia in extension replaced by an
unstable paraplegia manifesting spontaneous flexion jerks,
returning subsequently to the stable contracture i n extension.
This is not rarely observable in multiple sclerosis. Besides in
this illness, paraplegia in flexion is most often found in com-
pressional processes.
The flexor position may end in stable contracture. This is
supposed to be due to the active contraction of the muscles. If
such a case of illness is observed from its commencement in
extensor contracture, one will arrive at the clinical result that
extensor tonus and with it the patellar and ankle-jerks
decrease, while the flexors develop a n accessive reflex activity.
Even the slightest tickling of the sole of the foot will in such
cases elicit flexion reflex. Flexor spasm commences with
twitchings in the leg (>>cramp(()which apparently take place
entirely spontaneously, first one-.sided, subsequently double,
alternating with a more or less pronounced tendency to
synchronism and the flexor position may become manilest. It
will be understood that the commencement of paraplegia in
flexion is tantamount to a decline in the condition of the
patient.

11. THE COMPLETE TRANSVERSE LESIOX


The spinal cord when entirely separated from the cerebrum
can act as an independent reflex centre, manifesting reflex
activity, and it is only during recent years that some degree of
clear understanding of this has been gained. And this under-
standing has chiefly been acquired by studies of the traumatic
transverse lesion. The ordinary medullary diseases can of course
also lead to complete severance, but this will very rarely be
anatomically complete even ii, physiologically, the case
manifests itself as transverse lesion. It is chiefly the traumatic,
complete transverse lesion which is of clinical interest.
After a trauma of the spinal cord, whether resulting in
complete or incomplete fracture, that part of the spinal cord
which is caudal in relation to the lesion will be subject to SQ-
278
called shock. It is necessary in a few words to give some
guidance as to the meaning conveyed by this expression before
the symptomatology of the complete transverse lesion can be
dealt with.
According to Sherrington shock means the depression of the
nervous functions immediately following a mechanical insult
of one or other part of the nervous system, and is of transitory
nature. In our case shock means that that part of the spinal
cord which is distal in relation to the lesion is affected by the
shock phenomenon, experience from the W a r having shown
that the central extension is very slight or not even noticeable.
(Thus it is often seen in Riddoch’s descriptions of cases that
the patient has a subjective feeling of being divided into two
parts and that he is entirely conscious all the time). The term
.coma mCtdullaire(( (Lhermiffe) is pertinent. It has also been
found that the effect of shock decreases in a distal direction
so that the reflex arcs can here only be depressed to a slight
extent. Of the many possible causes of shock, most investigators
have adopted vasomotor disturbances and the so-called isolated
dystrophy i. e. secondary trophic disturbances arising on
account of severance of the connections between thc central
nervous elements. The shock stage lasts until reflex responses
can be elicited and varies in various cases.
Riddoch states that the first reflexes which return aiter shock
(if they have disappeared at all) are the contractions of the
external sphinters (retentio urinae et alvi). The next reflex
is the peculiar plantar reaction of the plantar reflex (Guillain
and Barre).
The average time for the return of the flexion rellex after
the shock was thirteen days in Riddoch’s cases, while on an
average the patellar jerk could not be elicited bfeore the lapse
of thirty-two days and this corresponds with the observations
of others. Automatic evacuation of the bladder commenced as
a rule three to four days after the lesion.
In cases which survive the trauma the reflex activity
increases little by little as the organism accustoms itseIf to the
new conditions and in time a very pronounced reflex activity
establishes itself.
Thus the symptomatology of the traumatic transverse lesion
may be divided into a shock stage and a reflex stage. It is a
question of opinion whether one should add to these a terminal
stage during which the reflex activity decreases little by little
as the frequent states of inflammation (urinary affections, bed-
sores, pneumonia etc.) undermine the general condition of the
patient. The reflex stage may last for months or years (in a
case operated on by Stewart and Harte the patient lived for
nineteen years after the operation). The terminal stage, if any,
will vary from a few hours to a few months at the most.
Having sketched the features of the shock stage I will - as
in the case of paraplegia in extension and flexion - pass to
the symptomatology of the complete transverse lesion in the
reflex stage.
Motility: The position is generally extended but it may also
be flexed. There is more or less pronounced atrophy.
Tonus: Atony does not always take place, at all events during
the first few days, in cases of traumatic transverse lesion. Later
on the muscles are felt to be flaccid or ,flabby((, the contour of
the extremities presents the recumbent oval (,breites Bein(().
Resistance is, however, noticeable in passive movement - i. e.,
tonus is present even if it does not manifest itself upon palpa-
tion of the muscles. Thus tonus will as a rule be characterized
as hypotonus, but in rare cases this resistance may be so
pronounced that the designation hypertonus becomes more
adequate. No active motility.
Sensation: Complete loss of sensation to all impressions
from the upper limit of the medullary affection.
Reflexes: Tendon and periosteal jerks will, as stated, return
in the course of four to five weeks. In the reflex stage they will
increase - both pedal and patellar clonus may be present. The
phase of relaxation of the patellar jerk is sharp and aplastic.
Cutaneous reflexes: The abdominal reflexes are absent. (The
confusion of these with reflex jerks of spinal automatism in
280

the abdominal muscles does not seem to be beyond possibility


even among neurologists, a s Monrud-Krohn has pointed out in
his book on abdominal reflex: ))Om abdominalreflexenecc).
The plantar reflex is often plantar, often dorsal, frequently
alternating.
Reflexes of spinal automatism: The reflexogenous zone
is very extended, often reaching to the abdominal region
and it may reach the lower limit of the spinal affection.
The reflex irritability is often excessively pronounced. It
may manifest wide variations a n d fluctuate with the reflex
zone from day to day. Great depression is often observed during
febrile periods and when the fever declines the reflex irritability
increases again. The reflex reactions are usually very lively,
chiefly engaging the flexors and marked by violent irradiation.
The flexion reflex may be ))as quick as lightning(( both in the
phase of flexion and extension, but the phase of extension is
slower than that of the flexion. When the reflex activity is
very great all the muscles below the lesion may take part in
the reflex reaction. In one of m y cases intestinal sound was
constantly heard when the flexion reflexes - which were
always double - took place.
))Mass-reflex(( a s described by Riddoch - double flexion
reflex, contraction of the abdominal muscles, evacuation of the
bladder and excessive perspiration - is a pathognomic sign of
complete transverse lesion but unfortunately it is not by any
means always present.
Crossed tonicization of the adductors and the extensors is
observed, but crossed extension reflex is rare although it may
be present.
Spontaneous one-sided or double reflex reaction may he
observed. .Stepping reflex<< a n d ),phCnom&ne d’allongemente
may be found. In short, there is hardly any reflex reaction
which cannot be elicited, but they are all discounted by their
rarity a s compared with the one-sided or double flexion reflex.
Organic Reflexes: Evacuation of the ldadder (but not entire:
there is always residual urine) a t varying intervals. The patient
has no sensation of urination and is not aware of the discharge
281

until he feels with his fingers that the bed is wet or hears the
sound of water in the urinal. Evacuation of the bowels take
place, to begin with only, at intervals of weeks unless a laxative
is employed.
T o recapitulate shortly the delineation of the disease: the
first phase, the shock stage, characterized not only by flaccidity
or >>flabbiness((of the muscles, but also by a suppression of the
organic functions; the second phase, the reflex stage, marked
by the return of muscular tonus accompanied by reflex activity,
lively reflexes of spinal automatism, appearance of spontaneous
reflex movements, automatic function of the bladder and
rectum, incomplete return of the genital function, increased
secretion of perspiration and hyper- irritability of the smooth
muscles of the skin. (Lhermiffe).
As may be seen from this exposition there is an essential
difference between the incomplete and the complete transverse
affection in several respects, of which the most marked are the
distribution of tonus and reflex irradiation. If a systematic
examination is carried out, it is in any case possible to
distinguish clinically between the physiologically incomplete
and the complete transverse affection. If not anatomically
complete this is of no significance in the clinique as restoration
can never be looked for.

THE CLINICAL SIGNIFICANCE OF THE REFLEXES O F


SPINAL AUTOMATISM
The lack of thoroughness with which the reflexes of spinal
automatism are dealt with in the text books in general use
forces me to say that their greatest significance lies in their
being recognized at all. It is not only necessary that doctors
should not fall into the error of supposing voluntary motility
to exist in a completely paraplegic patient, the spontaneous
actuation of the reflexes of spinal automatism being deceptive: it
is also necessary to realize that these reflexes have therapeutic,
prognostic and diagnostic importance.
282

As far as therapeutics is concerned I am thinking of the


treatment of the patient; it is necessary to know that a
spontaneous actuation of the reflexes of spinal automatism may
be the forerunner of a flexor contracture. It is distinctly un-
pleasant for a patient who is already suffering greatly to have
a flexor contracture into the bargain. This may be prevented by
the simple expedient of binding a sheet round the bed over the
legs to keep them at rest. If one has witnessed the sufferings
caused by this flexor spasm one will readily appreciate the
value of this simple arrangement. Besides the subjective
discomfort ugly bedsores will be caused by frequent rubbing
aginst the surface of the bed and this may also be prevented
in the manner described.
Prognostically one knows that the spontaneous actuation of
reflexes of spinal automatism - the commencement of
paraplegia inflexion - is tantamount to a decline in the condi-
tion of the patient.
The stages of disease which most need a prognostic guide
are, however, presumably the cases of traumatic lesions of the
spinal cord. The surgeon, who has the first treatment of such
cases will certainly be glad to have a prognostic hint as to the
extent of the process and guidance in deciding the question of
whether to operate or not.
As already mentioned the symptoms of shock disturb the
examination. As long as the spinal shock lasts it is altogether
impossible to elicit reflex responses - this is in the nature of
the shock stage. The reflex action which first appears after
the shock is the plantar reflex. When plantar reflex action takes
place one will not be far out in deciding on prognosis pessima.
Further it must be remembered that when the tonus decreases
and the muscles of the extremities gradually become flaccid
after the first two or three days, we have quite a good sign of
serious or incurable lesion. On the other hand maintenance of
tonus and a quick return of the reflexes indicate that an im-
provement may be expected.
Among the sure diagnostic signs in neurology the inverted
plantar reflex holds an important place as a practically unfail-
283

ing sign of pyramidal affection. It has already been pointed, out


that the dorsal motion of the big toe forms an integral part of
the flexion reflex when this is excited from the distal parts
of the extremities. Add to this the fact that the pathological
flexion reflex cannot be produced unless there exists an affec-
tion of the pyramidal tracts, and we have another clinical
means of identifying this disease. Even if cases of absence of
the plantar reflex, of dependence of the inversion on the
periphery ') or of immobility of the toes are not often met with,
it is not a bad thing to bear in mind that the flexion reflex is
a sure sign of affection of the pyramidal tract.
For differential diagnosis between imcomplete and complete
transverse affections the reflexes are indispensible. During the
shock stage after traumatic lesions the plantar reaction of the
plantar reflex will furnish a point of departure with regard to
complete transverse lesion. Inverted plantar reflex is according
to Gullain and Barre' exceptional in this first phase of serious
destructive medullary lesions and these investigators have sup-
posed that inverted plantar reflex observed during the first
few days after a traumatic medullary lesion warrants the
conclusion that there is no anatomatical or physiological
transverse lesion. These observations conform with those of
others (Gordon, Holmes, Riddoch, Dejerine and other).
If the examination is carried out in the reflex stage there are,
as already pointed out, several essential points of distinction
between complete and incomplete transverse lesion, so that
with a knowledge of the reflexes of spinal automatism and the
tonic conditions one ought to be able to make a correct
diagnosis.
Previously I have assumed that the reflex arc is intact.
Supposing that this is ruptured in the medulla, i. e. that the
lumbosacral cord is destroyed it will of course be just as im-
possible to obtain reflex reaction as in the case of cauda equina
lesions. The presence of reflex reaction is thus in itself evidence
of the fact that the lumbosacral cord is intact.

I) Monrad-Krohn and Lossius: Norsk Magazin f. laegevidenskapen, 1931.


284

I will deal finally with the significance of the reflex zone.


It is no easy matter clinically to diagnose the lower limit of
the affection of the spinal cord. A point of departure may be
found in the condition of the intercostal muscles, diaphragm
and abdominal muscles, but in addition to this there is, as
described by Babinslti and Jarkowski, the extent of the reflex
zone. In their cases the reflexes could be elicited all the way
up to the lower limits of the medullar lesion in compression
myelitis. Thus the reduction of sensation should indicate the
upper limit and the reflex zone of the reflexes of spinal
automatism the lower limit of the spinal affection, in segments.
I have had a n opportunity of studying a case of compression
myelitis and I can only conclude that what has just been said
is not always the case, as it was not possible a t any time during
the period of ohservation, which was, however, comparatively
short, to elicit reflex reaction above the seventh dorsal segment
even under the strongest excitation and even when all the
various kinds of stimuli were employd. In autopsy the spinal
affection was found to correspond to the fifth to seventh
cervical segment. It is, however, a clinical fact that the reflex
zone mlny extend right u p to the lower limits of the spinal
affection, not only in compression myelitis but also in the
reflex stage of complete transverse lesion. (A. Boisseau, Lher-
mitte and Cornil).

SUMMARY
1 . A wnrm bath of 37' C . provides the best condition for tlic scientific
investigalion of the reflexes of spinal automatism in man.
2. In the routine examination it is reconiinended to pinch thc anterior
aspect of the leg just above the ankle. If this inanipulation elicits
dorsal movement a t the ancle, it signifies, as pointed out by Babinski
- a lesion of the pyramidal tract. The method of Babinski is
therefore of greater clinical value t h a n the passive flexion of the
toes employed hy Pierre Marie.
3. The reflexes of spinal automatism on the whole furnish a fairly
reliable indication of a pyramidal lesion.
285
4. The crossed extension reflex is ( i n addition to the plantar and
flexion reflexes) of great value for the distinction between a coni-
plcte an d an incomplete transversal lesion of the cord, inasmuch ns
its presence usually indicates an incompleie lesion.
5. Within the reflexogenous zone the reflexes - i n all cases examined
- ar e found to hc more easily elicited from the inside t h an from
the outside of ihe calf, which disagrees with ihc findings of Riddoch.
6. The rcflexogerious zone of the reflexes of spinal automatism (par-
ticularly of the flexor reflexes) often extends over part of or the
whole of the abdominal area.

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