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 *B llfl m 
 
 
EXCHANGE 
 
 BlOLOGi 
 LIBRA** 
 
31 
 
 The Graphic Recording 
 
 of Reflexes, Clonus 
 
 and Tremors 
 
 A Thesis Submitted to the Faculty of the Graduate School 
 of the University of Minnesota 
 
 BY 
 
 R. EDWIN MORRIS, M. D. 
 
 IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE 
 DEGREE OF DOCTOR OF SCI1 
 
 1917 
 
 [Reprinted from MINNESOTA MEDICINE, July, 1919] 
 
 THE H. W. KINGSTON COMPANY 
 
 527-533 Minnesota Street 
 
 St. Paul, Minn. 
 
* -^Reprinted from MINNESOTA MEDICINE, July 1 
 
 THE GRAPHIC RECORDING OF REFLEXES, 
 CLONUS AND TREMORS. 
 
 R. EDWIN MORRIS, M. D. 
 
 of Medicine. University 
 Medical School. 
 
 Minneapolis, Minn. 
 
 Department of Medicine. University of Minnesota 
 Medical School. 
 
 In undertaking this work, two great prob- 
 lems were confronted 1st. The securing of 
 consistant constant graphic records of the re- 
 flexes, clonus and tremors ; 2nd. Their interpre- 
 tation and the underlying physiological basis. 
 
 So many were the difficulties and so great 
 the time consumed in attempting to solve the 
 first problem that all questions of interpreta- 
 tion will be deferred for later communication. 
 
 Prominent among the early workers making 
 accurate studies and contributions to our 
 knowledge of nervous phenomena, is Marshall 
 Hall 1 , whose findings, demonstrating the reflex 
 or excito-motor system of nerves, were pub- 
 lished in 1838. Within the next decade he dem- 
 onstrated that the posterior columns of the 
 cord were sensory, while the anterior were 
 motor in function. 
 
 Preceding and leading up to these important 
 discoveries of Hall, were several investigations 
 worthy of mention in this connection. J. H. 
 Miller 2 , of Baltimore, started his work in 1809 
 and demonstrated important functions in rela- 
 tion to the great sympathetic plexus of nerves 
 and included information relating to this work 
 in his lecture delivered at the Washington 
 Medical College in 1827. Brachet 3 , carrying on 
 researches in France, also made important con- 
 tributions. Perhaps most important, however, 
 
 444250 
 
m Ar'.the : brilliant discoveries of Sir Chas. Bell of 
 London 4 demonstrating the distinct sensory and 
 motor functions of the posterior and anterior 
 roots of the spinal cord. His publication ap- 
 peared in 1824. An earlier communication of 
 Hall's presented to the Royal Medical Society 
 of England in 1833 should also be mentioned. 
 
 Though the work of these men was conducted 
 independently, they arrived at the same general 
 conclusions and established definitely that the 
 sympathetic plexus is connected with the pos- 
 terior column of the cord and that the motor 
 impulses pass from the anterior roots. 
 
 Three other important contributions should 
 be mentioned before taking up the work of 
 Westphal and Erb. George Morton 5 , of Phila- 
 delphia, published a research in nerve physi- 
 ology in 1839, entitled "Grania Americanae. " 
 The work of Magendie Floures 6 on the relation 
 of the brain and medulla oblongata to the func- 
 tions of the cord, and that of H. H. Smith, 7 are 
 to be mentioned in connection with the develop- 
 ment of our knowledge of the various reflexes. 
 
 Since Westphal and Erb 8 recognized the 
 values and introduced studies on the knee jerk, 
 or patellar tendon reflex, it has been a fruitful 
 field for scientific research and extensive litera- 
 ture has been gathered about it. The work of 
 Puerbringer 9 on section of the cord in the upper 
 dorsal region of rabbits showed that lively knee 
 jerks could be elicited despite the claim of 
 Rosenthal and Mendelsohn 10 that, after trans- 
 section of the cord at different levels, the knee 
 jerk is lost, and that the production of the 
 reflexes required an intact arc in the region of 
 the cervical enlargement. 
 
 In the work of Gad and Flatau 11 with high 
 trans-section of the cord in dogs, weak knee 
 jerks were obtained or were sometimes tern- 
 
porarily abolished, though with low trans-sec- 
 tion of the cord the knee jerk continued. 
 
 A short time later Sherrington 12 conducted 
 comprehensive and extended studies on the 
 knee jerk in monkeys, doing trans-section at 
 various levels, and also observed carefully all 
 the other reflexes affected. His report shows 
 that knee jerks were lost for a time, though in 
 cats and dogs that were transsected at the same 
 time, the reflexes were not lost even on trans- 
 section as high as the cervical region. The re- 
 sulting shock produces a temporary disturb- 
 ance, which in man is of longer duration. 
 
 Following this Margulies 13 demonstrated that 
 cutting the cord produced lesions resulting in 
 flaccid palsy, and crushing the cord produced 
 lesions resulting in loss of the knee jerks. 
 
 Stewart P. Turner 14 concludes that, though 
 his findings were not constant on section in 
 other animals, in monkeys the higher the level 
 of trans-section the greater the likelihood of loss 
 of the knee jerk, while in man transverse injury 
 above the lumbar enlargement usually leads to 
 loss of the knee jerk, though in complete trans- 
 verse injury it abolishes it only temporarily. 
 Trans-section produces an impaired neuro- 
 muscular tone. Voluntary movement is abol- 
 ished while the true reflex is not impaired. A 
 great autonomy exists in the spinal segments 
 in maintaining neuro-muscular tone as we de- 
 scend the vertebrate scale. 
 
 The work of Buchanan 15 done with frogs, 
 particularly in electric stimulation and the 
 timing of reflexes, to my mind shows only that 
 the action of a carefully excised frog's muscle 
 suspended in salt solution will differ greatly 
 from that of the human muscle in normal or 
 abnormal conditions. Waller 16 did important 
 work along the same lines, publishing his re- 
 
 3 
 
suits in the early eighties. Lombard's work 17 
 on the normal knee jerk is one of the most mas- 
 terly studies made up to that time. In sum- 
 ming up his conclusions, he says "It is highly 
 probable that the tendon phenomenon is a 
 direct muscular contact and the integrity of the 
 nervous arc is necessary for its production." 
 
 Neuro-pathologists of the present day are 
 following the teaching of Bastian that the cord 
 is not the absolute center of reflexes: though 
 there appears with most transverse lesions an 
 increase in reflexes, the consensus of opinion is 
 now that the tendon reflexes are independent 
 of nervous action beyond the spinal cord. 
 
 Laborde (quoted by Jendrassik) reports in- 
 stances showing that tendon reflexes persist af- 
 ter decapitation: hence brain action is not re- 
 quired for the production of all reflexes. 
 Sahli 13 believes that the cerebrum is essential. 
 In contrast to the earlier ideas, Jendrassik 19 has 
 formulated a theory of reflexes which is based 
 upon clinical evidence and is worth care"ul 
 consideration, "Reflexes are spinal or cerebral 
 or a combination of the two." Sahli, discussing 
 the subdivisions of Jendrassik, says that "they 
 do not consistently hold good" and he suggests 
 that Jendrassik 's group 3 be 'called cortico- 
 nuclear, and those involving the spinal areas 
 of innervation be called cerebrospinal reflexes, 
 because in a transverse lesion of the cord the 
 cerebellar reflex arc is also interrupted and one 
 would expect a loss of cutaneous reflexes, but 
 this does not occur since the lesion interrupts 
 the sensory conduction through the cord and in 
 a measure dams the sensory stimulation. (Jend- 
 rassik 's group 3). To this group belong reflexes 
 which have complicated centers, within which 
 the reflex occurs, not as a single movement but 
 as a series of such, e. g., sneezing, vomiting, 
 
swallowing, coughing, urinating, defecating, 
 genital reflex (ejaculation). Therefore the 
 peripheral impulse must find a path in the 
 region of the lower cord segment. It generally 
 selects the customary path (the formed spinal 
 reflex arc) of the coresponding cerebrospinal 
 reflex and so the cutaneous reflexes become 
 purely spinal. This explains how many of the 
 preserved reflexes retain their complete and 
 identical distribution. It also explains how 
 other reflexes, by means of the damming up of 
 the exciting impulses at the lesion, attain both 
 abnormal intensity and distribution by trans- 
 mission of the impulse to the neighboring paths. 
 
 Sahli's theory contrasted with Jendrassik's 
 simplifies the scheme of reflexes. There are 
 two groups of reflexes: (1) spinal, or better, 
 nuclear, because some of them occupy the re- 
 gion of the cranial nerves and would include 
 the .tendon, periosteal and joint reflexes: (2) 
 the cerebrospinal or cerebro-nuclear reflexes, 
 including both normal, cutaneous and mucous 
 membrane reflexes and including also Jend- 
 rassik's group 3. In the latter group the brain 
 and spinal cord act normally together: that is, 
 the activity in the lower nuclear reflex arc is 
 under physiologic conditions discharged by 
 the cortex. In transverse lesions of the cord, 
 reflexes of the second group may originate ex- 
 clusively by way of the cord and so be in- 
 creased or even deformed by reflex damming. 
 
 Lombard 20 made careful studies in the varia- 
 tions of the knee jerk. Bowditch and "Warren 21 
 conducted interesting investigations as to the 
 time element in the knee jerk and the effect of 
 reinforcement. Waller 22 , in a very instructive 
 article, reviews the work of Lombard 23 and of 
 Bowditch and Warren and sums up in conclu- 
 sion as follows: "It is highly probably, that the 
 
tendon phenomenon is a direct muscular can- 
 traction and the integrity of the nerve arc is 
 necessary for its production." Devising some 
 new apparatus, he secured excellent records of 
 the knee jerk with time portrayal. On the com- 
 pletion of his experimental work with rabbits 
 he concludes: "The so-called tendon reflex is 
 a phenomenon of direct excitation, its lost time 
 is practically identical with that of direct con- 
 traction, whereas the lost time of a reflex con- 
 traction is three times as long". 
 
 Other experimenters have shown that the in- 
 tegrity of the spinal arc is a necessary condi- 
 tion. This time consideration as indicated by 
 Waller, is, in my opinion, the most effective 
 argument yet brought against the theory of 
 reflex contraction. 
 
 The reflex may be obtained with the patient 
 either in a sitting or recumbent position. If 
 the patient is in bed, flex the knee to an obtuse 
 angle, the heel resting on the bed, support the 
 knee with the left hand and tap the patellar 
 tendon with the hammer and if the contraction 
 is produced, the quadriceps extensor if the 
 reflex is active may cause extension of the leg : 
 if it is faint, the contraction may be just visible 
 underneath the skin, though care should be 
 taken that the jar of tapping the tendons does 
 not produce a movement that resembles the 
 reflex. Be sure that the muscles of the leg are 
 not tense. This can be tested by suddenly re- 
 moving the supporting hand and if the muscles 
 are relaxed the leg will drop to the bed. This 
 reflex may be reinforced according to the meth- 
 od of Jendrassik, pulling on the two hands 
 hooked together. 
 
 If the reflex is elicited with the patient in 
 sitting posture he is seated with legs crossed or 
 with feet flat upon the floor and legs as nearly 
 
vertical as possible. A better method is to have 
 the patient seated on a table or edge of a bed, 
 with legs hanging free. By placing the left 
 hand on the thigh above the knee while tapping 
 with the right hand, a contraction will be felt 
 with the left hand. On tapping the left fore- 
 finger placed over the patellar tendon, in- 
 creased extension of the tendon may be felt. 
 
 The method of Lanfanauer's reinforcement 24 
 may be used. The patient is seated with both 
 feet touching the floor, the examiner grasps the 
 quadriceps with the left hand and the patient 
 grasps the upper left arm of the examiner. As 
 the patient squeezes the arm of the examiner 
 the tendon is tapped with the hammer. In 
 Schonborn's method 25 of reinforcement the pa- 
 tient squeezes the left hand of the examiner 
 while the latter taps the tendon with the ham- 
 mer held in the right hand. 
 
 Knee jerks, as existing in apparently normal 
 individuals, are usually described as absent, 
 mild, strong and exaggerated. Very extensive 
 scales describing the degree of this phenomenon 
 have been used, as many as ten degrees or vari- 
 ations being described in thus designating the 
 strength of the reflex 26 . 
 
 A normal reflex is evidence that the spinal 
 segment, by which it is connected with the ex- 
 tremities of the arc, Fig. 1. is in a state of 
 physical harmony. When there is a diminished 
 reflex or an absence of reflex there is some inter- 
 ruption of the reflex arc. This arc leads from the 
 peripheral end organs, through the sensory 
 nerves leading to the posterior sensory gan- 
 glia on to the posterior horn through the seg- 
 ments, thence to the anterior motor roots in the 
 anterior horn and on to the muscle. 
 
 There are two great groups of reflexes, super- 
 ficial and deep. There is a superficial reflex 
 
Fig. 1. I 1 . Indirect (sensory) Tract, (Deep Reflex.) 
 
 1 2 . Indirect (involuntary) Motor Tract. 
 
 1 3 . Route of the Normal Reflex with Results 
 of Lesions. 
 
 action coming from the end organs in the su- 
 perficial tissue or at the surface of the skin: 
 and there is a deep reflex or action coming from 
 the muscle, bone or tendon. The superficial re- 
 flexes enter through the posterior root ganglia, 
 at the arc directly through the cord and leave 
 at the same level by way of their anterior 
 motor roots. The deep reflexes enter in the 
 same manner through the posterior root gan- 
 glia. From there they pass in part to the sen- 
 sory root of the cord where they enter and fol- 
 low the indirect sensory tract of the cortex. 
 
(Fig;. I 1 .) Others pass through the posterior 
 horns to the anterior horn where the sensory 
 impulse is translated to a motor response. 
 (Fig;. I 3 .) Where the p-overnine: fibres from the 
 cortex through the indirect motor tract join the 
 reflex arc, the governing action either is in- 
 hibited or accompanied by the impulse from the 
 cortical area. (Fig. I 2 .) From the anterior horn 
 cell the impulse passes along the motor nerve 
 to the muscle. 
 
 Phelps 27 , in a study at the Minnesota State 
 Hospital for the Insane at Rochester, has care- 
 fully searched the literature of the knee jerk. 
 He says, "Rather surprisingly there is no scale 
 by which to measure the degree of this phe- 
 nomenon." In his work he finds that in some 
 persons the knee jerk was quick and short: in 
 others, longer and slower. In one hundred 
 normal subjects (attendants) there was one 
 case of absent reflex. This case was observed 
 over a year and also two normal individuals 
 showing the opposite extreme an ankle clonus. 
 He estimates that in about two per cent of 
 healthy people the knee jerk is absent, though 
 Jendrassik's method of reinforcement succeeds 
 in eliciting it. 
 
 Recently a strong reaction against the pre- 
 valent conception of muscular tonus has set 
 in 28 . It is maintained that there is no such 
 thing as a general contraction of muscle when 
 at rest, but that a so-called tonus is the co- 
 ordinative performance that calls forth a cer- 
 tain attitude by means of finely graduated con- 
 tractions. 
 
 Many of the so-called pathologic reflexes 
 should be regarded as deformations of the nor- 
 mal reflexes depending upon the encroachment 
 on the reflex impulse of the pathways which be- 
 come accessible to the impulse only because of 
 
 9 
 
an obstruction which is interposed in the or- 
 dinary reflex tract and in consequence of the 
 reflex damming. The reflex, though modified, 
 can still be recognized. In other cases reflexes 
 occur as pathological phenomena, a peculiar 
 exageration accompanied by reflex movements 
 of a distinctly muscular type. 
 
 Sahli 29 , in closing his chapter on a discussion 
 of the segmental localization of the spinal cord, 
 says ' * The frequent contradictions which exist 
 between the different writers show how unset- 
 tled the question remains ; that accurate clinical 
 and pathological examinations will not only 
 supply numerous corrections but will extend 
 our knowledge as well. These findings, es- 
 pecially where they concern the reflexes and 
 their relation to the segments, must be critical- 
 ly examined for light on the genesis of re- 
 flexes." 
 
 Engaged in electrocardiographic studies dur- 
 ing the years of 1914 and 1915 and noting in 
 these records the deflections (extra-cardiac or 
 extraneous) produced by voluntary muscle 
 movement, the writer began a more system- 
 atic study of extraneous voluntary and in- 
 voluntary movements. A normal muscular 
 contraction produced a definite curve or series 
 of curves while muscular contractions asso- 
 ciated with some pathological conditions, as 
 tremors, produced a definite type of oscillations 
 of the galvanometer string. These oscilla- 
 tions passed through stages according to the 
 degree of involvement, to a definite series of 
 rhythmic oscillations as observed in clonus. 
 Noting the constant recurrence of these rec- 
 ords of muscular response, serious attempts 
 were made to secure definite records of con- 
 traction of different groups of muscles. Se- 
 
 10 
 
curing constant results from these, attempts 
 were made to secure records of various reflexes. 
 
 The results were so promising that early in 
 the spring of 1916, with the assistance of Dr. 
 Henry "W. Woltmann, a systematic study of 
 various reflexes and tremors was begun and 
 graphic records were made with the string 
 galvanometer, using the same instrument as 
 that employed for studying action currents in 
 the heart. 
 
 Our instrument is the Cambridge Modifica- 
 tion of the Einthoven String Galvanometer, or 
 electrocardiograh. (Fig. 2.) 
 
 Our earlier records were secured at the time 
 of making the regular electrocardiographic 
 runs, at the electrocardiographic station: with 
 the recording apparatus in Millard Hall, Uni- 
 versity of Minnesota: the sending stations on 
 the different floors of the University Hospital: 
 the connection through under-ground cables 
 some 1390 feet long. Communication with the 
 operator was had by telephone wires passing 
 through the cable. 
 
 In the fall of 1916 we returned to Millard 
 Hall, taking records with the patients in the 
 same room with the recording apparatus. The 
 records obtained are identical in type with 
 those from the hospital. The writer has made 
 several new appliances, among them a device 
 for recording the mechanical swing of the leg 
 simultaneously and on the same moving photo- 
 graphic paper with the record of the electric ac- 
 tion of the string galvaro meter. Electric con- 
 tact is made by recording the exact time of the 
 blow, giving the signal on the margin of the 
 paper. 
 
 Our attentions has been centered principally 
 upon the study of the knee jerk and in record- 
 ing this reflex. The i ppar^tus as new (m 
 
 11 
 
Fig. 2. Apparatus in use at Millard Hall, University 
 of Minnesota. 
 
 ployed consists of a chair (Fig. 3.) (1) with 
 arms and back in order that the patient may 
 sit in as comfortable a position as possible. 
 The chair is elevated sufficiently so that the feet 
 swing free from the floor. Attached to the 
 front edge of the chair are two light boards 
 (F) that are fastened to the back of the pa- 
 tient's leg. The upper end of each board is at- 
 tached by a hinged joint to a rod (T) that runs 
 along the front edge of the chair, permitting 
 a lateral movement in order to adjust the leg 
 boards comfortably to the legs of the patient. 
 A vertical rod (E) passes through the centre of 
 the front edge of the chair passing through a 
 collar and is held in place by a set screw (V) 
 so that it can be raised or lowered in adjusting 
 the hammer position. The rod bends forward 
 at right angles at the upper end and to this is 
 attached a double set screw (S) which holds 
 in position a rod (M) that passes at right 
 angles to the forward end of the hammer sup- 
 
 12 
 
port and is parallel to the front edge of the 
 chair. This rod supports the hammer (C) in 
 position so that with proper adjustment it will 
 strike the knee in the same spot each time and 
 give blows of the same intensity as many times 
 as desired. The "electrical release" was tried, 
 but catching the hammer on the rebound with 
 the hand and elevating it to the desired po- 
 sition, then releasing, permits using a much 
 simpler apparatus. 
 
 Several types of hammers have been used. 
 Our earlier work was done with the ordinary 
 percussion hammer, the blow being given with 
 the hammer held in the hand of the observer. 
 Later this was modified in order to record elec- 
 trically the moment of the blow. A little later 
 the writer devised the swinging hammer held in 
 position by the support described above. A 
 small metal-headed hammer was used, the metal 
 head being placed in electric circuit, a small 
 piece of metal gauze (D) being placed over the 
 patellar tendon and being insulated so that no 
 portion of it touched the body. This was placed 
 in the circuit with a signal magnet placed at 
 the lower or right edge of the slit of the re- 
 cording apparatus of the electrocardiograph. 
 Thus at the moment the hammer touched the 
 knee the circuit was closed and a record made 
 of the moment of contact. The loss of time 
 that occurs by the use of this method amounts 
 to approximately one fourtieth of a second. 
 The hammer handle has five holes in it which 
 permit it being hung upon the adjustable rod 
 in such a manner as to allow adjustment for a 
 blow of greater or lesser force. 
 
 The necessity of exact control in the strength 
 of the blow early became apparent. This was 
 accomplished in two ways. 1st. by varying the 
 length of the arc through which the hammer 
 
 13 
 
Fig. '3. The chair and its attachments, used in Ob'ain- 
 Reflexes. Also apparatus (below) in obtaining 
 Clcnus Record. 
 
 fell, by suspending the hammer through differ- 
 ent holes in the handle, 2nd, by allowing it to 
 fall either 45 or 90 degrees. Figure 5a shows 
 effect of dropping the hammer alternately 
 through 45 and 90 degrees, and figure 5b, the 
 same with re-enforcement. 
 
 The later model of hammer has a double con- 
 tact head that does away with attachment of 
 the metal gauze connections with the leg so 
 
 14 
 
that, when the blow is struck, a cap over the 
 head of the hammer, but not in contact with it, 
 is forced into contact, closes the circuit and 
 produces the swing of the signal magnet indi- 
 cating the moment of the blow. The apparatus 
 is arranged so that both legs are attached, dou- 
 ble swing boards and electrodes being used. 
 This permits the securing of repeated records 
 of the same leg or of the opposite leg under the 
 same conditions without disturbing the subject. 
 
 The electrocardiograph, such as we use in 
 securing our cardiac records, consists of three 
 units a lamp, recording apparatus, and an 
 Einthoven string galvanometer. 
 
 In securing records of knee jerks, the subject 
 is seated in the chair described above, attach- 
 ments are made to the galvanometer by means of 
 electroces (K and L) similar to those used in 
 our electrocardiographic work, one electrode 
 being placed upon the knee (L) and one placed 
 on the chair (K) so that it comes in contact 
 with the sacral region. The wires leading from 
 either electrode pass directly to the string gal- 
 vanometer though it is possible to carry them 
 to any distance.* 
 
 The attachment to the string galvanometer 
 are connected to Lead I and Lead II of the 
 switch board and if a third record is desired, 
 with attachment not only from the knee to the 
 sacrum but to the spine, there is attached the 
 Lead III which permits securing further 
 records without disturbing the subject by sim- 
 ply throwing a switch as in cardiographing. 
 
 Various time markers have been used, giving 
 records of one-tenth to one-hundreth of a sec- 
 ond. The one-tenth second marker is the one 
 usually employed by us and is of the Harvey type. 
 
 *At present we are taking records in the same room 
 with the apparatus and also from the University Hos- 
 pital, a distance of about 1,500 feet. 
 
 15 
 
Fig. 5. Shows effect of dropping the hammer alter- 
 nately through 45 and 90 degrees. 
 
 The apparatus for securing the mechanical 
 swing consists of the swing board (F) in the 
 inner edge of which are inserted three eye- 
 lets (0), to one of which is attached a hook 
 which is secured to an inelastic cord which runs 
 over an adjustable frictionless pulley (H) to a 
 hanging indicator suspended in front of the 
 aperture in front of the lens of the electro- 
 cardiograph. The indicator produces a shadow 
 parallel to that of the string galvanometer. 
 Holding the indicator in position on the other 
 side is a coiled ^e 1 rringr (B in P Fia;. 2), 
 the tension of which is adjustable. So long as 
 the indicator remains in a vertical position the 
 tension on the string leading to the swing board 
 is constant. This apparatus has given very con- 
 stant and satisfactory results and produces a 
 record that is of the highest value. 
 
 The record, as it appears, from a comparative 
 point of view at the extreme left or upper side 
 of the paper as ordinarily held, indicates the 
 movement of the time marker : next comes the 
 record of the galvanometer string: and then 
 the record of the mechanical indicator : and at 
 the extreme right or lower side of the record is 
 the record of the time indicator. 
 
 One great difficulty that presented itself in 
 securing records of reflexes was the adjustment 
 
 16 
 
of the string of the galvanometer so that 
 records of a constant value could be secured. 
 To overcome this the following method was 
 used. When ready to secure a record, the sub- 
 ject being properly attached and the photo- 
 graphic record paper started, one millivolt of 
 current was thrown into the circuit from the 
 switch board, the string of the galvanometer 
 having been adjusted previously so that as 
 nearly as possible to secure a deflection of 10 
 mm. The introduction of this millivolt of cur- 
 rent thus produces a deviation of the string so 
 that the width of this primary deflection repre- 
 sents 1 millivolt (Fig. 4. )Thus we have a 
 means of comparing the different records. 
 
 As a routine practice in recording knee jerks, 
 we make three records of each limb, starting 
 with the left : first the knee jerk, then the knee 
 jerk doubly reinforced, and then a voluntary 
 swing representing as nearly as possible the 
 swing produced by the reflex. The greater care 
 has to be used in securing the normal reflex to 
 have the patient in as easy and comfortable a 
 position as possible, with the eyes closed and 
 the thoughts diverted from the reflex problem. 
 Early in our work we found that the patient, 
 being on the qui vive, and the operator of the 
 galvanometer saying "Now" when ready, pro- 
 duced a reinforcement or increase of the reflex. 
 Since then the operator signals by raising the 
 hand when ready. In securing the reinforced 
 knee jerk, a double reinforcement is used. The 
 subject watches the hammer drop and, the mo- 
 ment it is released, pulls quickly. This rein- 
 forcement in most cases produces a marked in- 
 crease in the electrical reflex Fig. 6 though 
 in some subjects it has more of an inhibitory 
 effect on the mechanical, the subject holding 
 the muscles tense. 
 
 17 
 
There is a marked increase in sluggish re- 
 flexes when reinforced by Jendrassik's method. 
 In Fig. 7 this is well shown. While on the other 
 hand reinforcement may have a tendency to 
 decrease secondary and tertiary swings. This 
 is well shown n Fig. to, in which rec 1 and 
 3 without reinforcement should be compared 
 with 2 and 4 with reinforcement. In our ear- 
 lier work, the records taken were "f s", full 
 swing, "s r" swing and return, that is the leg 
 was stopped after completing one outward 
 swing and return to stop. These records do not 
 show the secondary and tertiary swings. As in 
 Fig. * hoi h tN re was o ten a jar o re- 
 bound that was shown. Later records con- 
 sisted of (a) the direct blow, (b) the blow re- 
 inforced, (c) the voluntary swing, resembling 
 nearly as possible the ; movement caused by the 
 reflex swing of the leg, with as complete relaxa- 
 tion as possible. The patient, having been in- 
 structed as to the voluntary swing, on signal 
 kicks as nearly as possible in the same swing 
 as produced by the reflex. 
 
 Three records are usually taken of each 
 different phase for comparison. It is in- 
 teresting to note in certain so-called normal 
 cases that there may be a marked increase or 
 diminution of the reflex evidenced with suc- 
 ceeding blows. 
 
 In' securing a record of the knee jerk, the 
 patient is seated comfortably in the chair with 
 sufficient clothing removed to easily get at the 
 parts desired. The electrodes are placed in 
 position with the same care as in cardiograph- 
 ing, being covered with a warm felt pad satura- 
 ted with salt solution and this in turn covered 
 with a piece of tissue paper. With the finger 
 as a hammer, the point of greatest reflex action 
 is located and this marked with a pencil. 
 
 18 
 
The leg swings are then secured to the leg and 
 the cord to the mechanical indicator is attached 
 and adjusted. The hammer is then placed in 
 position and adjusted so that the point of great- 
 est blow comes directly upon the spot pre- 
 viously marked. If a stronger blow is desired 
 the hammer is moved to one of the holes higher 
 in the handle. The indicator wire can be placed 
 in position so that a blow of either 90 or 45 
 can be determined. This means that a blow of 
 half or full strength can be determined without 
 rearranging the apparatus. Fig. 5. 
 
 The difference of the knee jerk as observed 
 by the eye and as recorded by our graphic 
 methods is indeed marked. The knee jerk as 
 ordinarily elicited may appear to be very simi- 
 lar, but by the graphic methods of recording 
 may be extremely different. Cases, that by the 
 ordinary method show no knee jerk, may, by 
 the graphic method, show a marked electrical 
 reaction with the str ny g Ivsnomet^t. F sj. 7 
 The initial reflex action is evidenced by the 
 rapid oscillation of the string resembling the 
 sharp pointed R-wave of the cardiogram. This 
 is usually of the diphasic type as the R-S wave, 
 Fig. 6 3 , though in occasional records, as in neu- 
 ritis, it may even appear as quadriphasic. This 
 wave which we deem the true reflex action oc- 
 curs in a very small fraction of a second after 
 the blow is struck on the patellar tendon. Fol- 
 lowing this wave comes a wave or series of 
 waves that are identical with the waves secured 
 in the voluntary swing of the leg of equal 
 length. Various factors, such as fatigue, drugs 
 and toxic conditions in general, seem to influ- 
 ence the width of excursion of this reflex ac- 
 tion, but the individual type of record remains 
 constant and its relation to the inception of the 
 oscillation due to the mechanical swing of the 
 leg is the same. 
 
 19 
 
Fig. 6. Tracings 1 and 3 show left and right K. K. 
 Tracings 2 and 4 show same reinforced. 
 
 Certain cases show a positive initial deflec- 
 tion indicated by movement toward the upper 
 right side of the records and is usually of op- 
 posite polarity to the reflex itself. 
 
 The reflex is of very short duration, about 
 one-fortieth of a second. At present we have 
 not the means at hand to accurately measure 
 this, though later we hope to make a study of 
 the various time elements. The mechanical 
 swing of the leg usually begins one-tenth of a 
 second after the reflex action and may consist 
 of a single swing, or as many as five. The time 
 element varies greatly in the swing in return- 
 ing to the base line. If the subject holds the 
 leg tense it is evidenced by a slower ascent and 
 gradually receding descent of the marker to 
 the base line, Fig. 4. This has been termed, 
 by older writers, the " inhibitory effect." 30 
 
 The knee jerk varies in different individuals 
 under different normal conditions. Though 
 they are constant under similar circumstances, 
 they may be greater early in the morning than 
 later in the day (fatigue) : increased after 
 
 20 
 
meals: increased by mental activity: increased 
 by cold, voluntary movements, strong sensory 
 sensation, or emotion. They are lost in sleep 31 . 
 
 In the work of Lombard, 32 Bowditch, 33 War- 
 ren 34 and Noyes 35 elaborate examinations were 
 made of this feature of the knee jerk and exten- 
 sive records were made from a subject by use of 
 a delicately constructed apparatus. 
 
 Diller 36 examined the knee jerk of 103 stu- 
 dents whom he considered normal. In no case 
 was the phenomenon absent, though in one-fifth 
 of the cases it was difficult to elicit, and re- 
 peated blows were necessary to bring it out. 
 His conclusions were that the knee jerk varied 
 greatly in length and rapidity of excursion. He 
 says, "It would be desirable to measure defin- 
 itely and record both of these elements ". 
 
 Mitchell and Lewis 37 , in summing up an ex- 
 tended research of the knee jerk, say "In 
 some the same weight of blow causes pretty 
 constant effect when steadily repeated at like 
 intervals, but in others the effects are incon- 
 stant and a series of slight motions are apt to be 
 followed by an excessively exaggerated act. 
 Such persons make bad subjects for experi- 
 mentation. This explosiveness is also apt to 
 follow much excitation of the muscle. Even in 
 the young and healthy the knee jerk varies 
 markedly. It is more marked in the morning, 
 in relaxing states of the weather, disability, 
 exhaustion, all tending to lessen the ease of the 
 reply to the tap. ' ' 
 
 The fatigue of a reflex is sometimes responsi- 
 ble for mistakes in diagnosis 38 . The response 
 to the first tap should be observed attentively 
 because it may disappear after one or two repe- 
 titions. In testing periosteal and tendon re- 
 flexes it is especially important to use great 
 care in eliciting reflexes, and to distract the at- 
 
 21 
 
Fig. 7. Reinforcement of Sluggish Reflexes. On left 
 are group with small action. On right, 
 same under reinforcement. 
 
 tention of the patient from the part to be ex- 
 amined, for through voluntary tension the re- 
 flex may be inhibited. 
 
 Individuals show a constancy in type of re- 
 flex that has continued through the period of 
 our observations. The quickness with which 
 the knee jerk responds and the muscular swing 
 following are always of the same general type 
 though they may be modified by various fac- 
 tors. 
 
 Knee jerks elicited early in the morning are 
 much greater than those secured from the same 
 individual later in the day or following exten- 
 sive physical exercise. Fatigue exercises a re- 
 markable influence on the strength and quick- 
 ness of the reflex. I have taken records of 
 runners under normal conditions and immedi- 
 ately following long cross-country runs. These 
 records show decided lessening in all their 
 forms. I have taken records, using the same in- 
 dividual, and secured records of repeated 
 blows. Certain individuals show no marked 
 change, though innumerable taps may be given, 
 while others may show an increasing reflex and 
 
 22 
 
others a diminishing reflex with succeeding 
 taps. 
 
 S. Weir Mitchell 39 says of Jendrassik's rein- 
 forcement that, "The discovery as to the power 
 of the voluntary volitional muscular movement 
 acts to increase the amount of the knee jerk". 
 His conclusions are "The knee jerk is a true 
 reflex caused by mechanical irritation of the 
 nerves of the tendon. Duly repeated excita- 
 tion of the knee jerk in some healthy persons 
 increase the knee jerk. Some cases show grad- 
 ual loss to oft repeated taps and the muscle 
 ceases to contract. Such movements as frown- 
 ing, moving the scalp or ears, moving the eyes, 
 all act as reinforcements. Inspiration and ex- 
 piration act as a decided reinforcement. Sneez- 
 ing, laughing, acts of phonation, swallowing, 
 and all of the coarser muscular acts increase 
 the knee jerk. Pain, intense fear and cold 
 also increase it.'* 
 
 Lombard 40 , studying the knee jerk variations, 
 demonstrated that fatigue, hunger, enervating 
 weather and sleep were conditions which in- 
 creased the activity of the whole nervous sys- 
 tem, and, in consequence, the activity of the 
 knee jerks. 
 
 It is a constant observation that the re- 
 flex action of the right leg is more marked than 
 the left, as is also the accompanying muscular 
 reaction. This is still more increased by rein- 
 forcement. Inflammatory conditions of muscle 
 and nerve bring out a marked reflex in- 
 crease together with an increased muscular 
 response, though here the action is more irreg- 
 ular due to the irritation present. Former 
 injuries and cases giving a history of neuritis 
 show marked decrease even to absence of the 
 knee jerk on the affected side. At all times 
 great care must be used in securing the knee 
 
 23 
 
03 OJ 
 ,Q 0> 
 
 I 
 
 II 
 
Fig. 8. Knee Kick in Case of Multiple Sclerosis, 
 a) Time marker, b) Electrical response. 
 c) Mechanical response. 
 
 jerk, for, should the first response to the tap 
 be small, the examiner might consider the knee 
 jerk absent. He must observe each reflex 
 quickly and accurately and make careful re- 
 peated examinations in order to determine 
 definitely their presence or absence. 
 
 Sahli 41 says "Any psychic excitement con- 
 siderably increases the tendon reflexes and this 
 increase may serve as an important sign of the 
 states of psychic excitement. The diminution 
 of reflex sometimes observed in very acute, espe- 
 cially in traumatic, cord lesions is acceptable to 
 the theory that this diminution is due to inhibi- 
 tion or to injury to the lower cord segments 
 fr.om circulatory disturbances from the injury. " 
 
 An injury to the cord produces a definite type 
 of symptoms. The amount of trauma can only 
 be determined by time, for a slight injury may 
 show an absence of knee jerk for a few days 
 followed by complete restoration of this reflex. 
 In the more severe lesions a trauma may show 
 complete loss of the knee jerk with no return, 
 due to shock. These produce disturbances of 
 the circulations which clear up within a few 
 days. Any inflammatory condition of the 
 nerves of the leg will cause an increase of the 
 
 25 
 
Fig. ' 9. Tracings 1 and 3 show sluggish reflexes, 2 and 
 4 same, 45 minutes after gr. 1-10 strychnia. 
 
 knee jerk. Sciatica, for example, produces a 
 marked increase of the affected side that grad- 
 ually becomes normal as the inflammatory con- 
 ditions recede. A hemiplegia, due to hemor- 
 rhage, produces a broken arc in the upper arc, 
 thus cutting off the inhibition factor and caus- 
 ing a greater knee jerk on the opposite side 
 from the lesion. 
 
 As has been mentioned before, a few appar- 
 ently normal cases show absence of the knee 
 jerk (Westphal's sign) 42 by the ordinary clin- 
 ical method of eliciting it, yet, with our method 
 of graphically recording reflexes, a minute elec- 
 tric reflex action Fig. 9 1 , followed by an elec- 
 tro-muscular action is recorded. 
 
 Pathological conditions such as fatigue 43 , 
 anesthesia narcosis, tabes 44 , Fig. 10. Entire 
 absence of any leg swing is known in this con- 
 dition. This failure is not mechanical. A large 
 number of the tabetics have failed to show any 
 
 26 
 
effects whatever ^of electrical change when the 
 attempt is made to elicit the knee kick. Fig 10. 
 Three tracings taken at three different times, 
 over a period of two months. On the left the 
 reflex record and on the right the voluntary 
 swing. Diabetes, paraplegia, poliomyelitis, and 
 in acute infections for a short 'time, also the 
 effects of certain drugs as opiates, may cause 
 a diminution of the reflex action from a clinical 
 standpoint, though, by our graphic method of 
 recording, these cases will show a small reflex 
 with a small electro-muscular and mechanical 
 response. In students we made a careful study 
 of the reflexes as effected by various drugs, 
 among which were recorded, prior to and .one- 
 half hour subsequent to the administration of 
 caff em, grs. 5, and of strychnia sulphate, one- 
 tenth gr, An increase following caffein and an 
 increase following strychnia, and with in- 
 creasing response, each succeeding blow. The 
 caffein relieving apparent muscular irrita- 
 tion, while the strychnia increases the irrita- 
 bility. In transverse lesions of the cord 45 , the 
 cutting off of inhibition from the centers above 
 markedly increases the reflexes. As a rule the 
 knee jerk is permanently absent after total 
 transverse lesions of the spinal cord above the 
 level of the arc (Bastian's law), but the reason 
 is not known. 
 
 Certain pathological cases present an in- 
 crease of both reflexes and muscular action, 
 such as myelitis, spastic paraplegia, multiple 
 sclerosis 60 . (Fig. 8) and lesions that cause a 
 degeneration of the cord itself. Any irritable 
 condition of the muscle, as in some of the toxic 
 states whether from stimulant drugs as strych- 
 nia, (Fig. 9) or internal conditions, increase 
 the knee jerk. 
 
 27 
 
Fig. 10. Tracings from Tabetic, over period 3 months. 
 
 Many times we secure records of knee jerks 
 that present peculiar formation in type, a char- 
 acteristic form both in reflex and muscular re- 
 sponse, apparently due to the predominant 
 action of certain groups of muscle bundles in a 
 definite manner. These individual types per- 
 sist so that repeatedly we have obtained similar 
 peculiar records from the same subject. 
 
 CLONUS. 
 
 Clonus may be defined as a reflex irregular 
 contraction of muscles. In any muscle in an 
 irritable stage with increased tonus, the ten- 
 dency to clonus action is greater as the tone 
 increases. The principal clonus described by 
 clinicians are the ankle clonus, the patellar 
 clonus and the jaw clonus. In securing ankle 
 clonus, the knee is slightly flexed, the heel rest- 
 ing on the palm of the examiner 's left hand and 
 his right hand grasping the foot, extending it 
 and suddenly dorsi-flexing the foot upon the 
 leg. An initial series of clonic involuntary con- 
 tractions of the muscles of the calf is elicited 
 and repeated under sustained pressure of the 
 flexing hand. This constitutes true clonus. The 
 patellar clonus is elicited, while the knee is 
 flexed and the heel resting in the examiner's 
 hand as before, by making quick and sudden 
 
 28 
 
pressure with the thumb and forefinger and 
 suddenly pushing patella downward and holding 
 it firmly. A clonus of the quadriceps extensor is 
 thus produced. The jaw clonus is produced in 
 a similar manner by suddenly throwing press- 
 ure upon the masseter muscles. 
 
 True clonus has the same significance as ex- 
 aggerated knee jerk, and its relation to organic 
 disease is most common in disseminated and 
 lateral sclerosis. "If contractions appear be- 
 fore the degree of foot flexion exceeds a right 
 angle and are evidently voluntary, irregular 
 and fleeting, then one is dealing with spurious 
 clonus, usually hysterical" 46 . Clonic convul- 
 sions are rapid involuntary muscular move- 
 ments repeated in shocks or series of shocks 
 with force and rapidity. They are never oc- 
 casioned by peripheral excitation of the motor 
 nerves. There appears to be an accumulative 
 irritability centre whose action may be com- 
 pared to that of the Leyden jar, and seems to 
 be essential to set off the shock-like explosions. 
 Clonic contractions are practically always ac- 
 centuated either by direct or reflex irritation of 
 the motor centre whether it be the nuclear or 
 psycho-motor centre of the cortex. Tonic con- 
 vulsions, long continued, produce rapid con- 
 traction of the muscle which may suddenly 
 change by implication and position or tension 
 of muscle. It may be associated with or trans- 
 formed to the clonic variety. A joint firmly 
 fixed by the muscle contracted about it so that its 
 movements are difficult or impossible is a con- 
 dition called a contracture. The increased ten- 
 sion of the muscle may depend on increased 
 tonus. The active contraction is an irritative 
 reflex contraction while the passive contraction 
 is a nutritive shortening of muscle. Active 
 contractures may occur where muscle tone is 
 
 29 
 
Fig. 12. Records of Tremors, normal type. 
 
 increased since muscular tone is of reflex 
 origin. 
 
 Bodwitch and Warren 47 , in an article, say 
 " There is good evidence that clonus is a 
 mechanical act the same as the knee jerk, hence 
 should be similarly influenced by the peripheral 
 nerve stimulation. Clonus may be reinforced or 
 inhibited the same as a normal knee jerk of a 
 healthy individual." 
 
 Ankle clonus presents a definite record by 
 the graphic method that will materially assist 
 in a better understanding of the work. To the 
 unaided eye all clonus appears alike, but rec- 
 ords show that there are three distinct types 80 
 due to fundamental genesis underlying as 
 in a case of chronic lenticular degeneration, 
 hematomyelia and primary sclerosis. A con- 
 stant record may be obtained not only showing 
 the rate and frequency of the clonus but also 
 its strength as recorded by the width of oscil- 
 lations and also the duration, whether main- 
 tained for some time or quickly dropping off, 
 and the question of its fatigue is recorded in a 
 permanent and definite manner Fig. 15. 
 
 The apparatus used in securing records of 
 clonus is shown in Fig. 3. The arm band 
 (Ss.) and pump of a blood pressure apparatus is 
 fastened about the limb from which the record 
 is desired. Tubing leads to the Marey tambour 
 
 30 
 
(R) which replaces the recording apparatus 
 used in securing the mechanical swing of the 
 knee jerk. Slight inflation is made with the 
 pump. The electrodes are used as in securing 
 the knee jerk and are attached to the string 
 galvanometer. 
 
 TREMORS. 
 
 Among the earlier medical writers was Clau- 
 dius Galen 48 who noted the fact that tremor 
 existed and differed during voluntary move- 
 ment and repose. Later Vieussens, in the latter 
 part of the 14th century, was the first to point 
 out the distinct and separate parts of the brain, 
 and wrote extensively on the subject of tremors. 
 
 Haller 49 , in 1708, in researches on irritability, 
 established the existence of irritability as a 
 property of living muscular tissue and that sen- 
 sibility was due to the nerves alone. 
 
 Gilson 50 , the successor of Harvey, in the mid- 
 dle of the 17th century brought out many new 
 discoveries regarding nerve tissue. The doc- 
 trine of irritability, as taught by Haller, lead 
 to a greater physiological study of nervous 
 tissue. 
 
 James Parkinson 51 , of London, in 1817 pub- 
 lished his essay on shaking palsy and this is his 
 greatest and most important contribution to 
 Medicine. Parkinson's definition is "Involun- 
 tary tremations, motion with lessened muscular 
 power in parts not in action even when 
 supported. ' * 
 
 Tremors are rapid, minute muscular contrac- 
 tions with a rhythmic tendency. Tremor may 
 appear in healthy individuals as well as in 
 pathological states, hence the need of careful 
 study and record. It may appear in normal 
 individuals following physical exercises, mental 
 agitation, cold, etc. Tremors are of two classes : 
 
 31 
 
Fig. 15. Record of Ankle Clonus, 
 (a) intention, or that occurring during pur- 
 poseful movement, and (b) passive, or that 
 tremor persisting during rest. Putting the in- 
 dividual muscle group in action or under con- 
 tinued strain increases tremor. All tremors of 
 the extremities are increased by extension and 
 may be wholly absent when the patient is at 
 rest. Most tremors are a spastic phenomenon 
 and the centres are located above the reflex arc. 
 Sahli 52 believed that tremors are essentially 
 manifestations of spasm just as every spasm is 
 explained by the damming up of stimuli which 
 causes an explosive instead of a constant dis- 
 charge of stimuli from the ganglion cells. It is 
 analogous to the spark discharge of an induc- 
 tion apparatus in contrast to the spray-like 
 brush discharge following low resistance. To 
 continue the analogy to explosive discharges 
 further, we see that the succession of impulses 
 underlying tremors may be based on the 
 stronger stimulation of the motor ganglion cells 
 on the one hand through the central neuron 
 (paralysis agitans and nerve excitability), or 
 through the reflex pathways (multiple scler- 
 osis) on the other, because of the interruption 
 of the motor current (peripheral palsies, fa- 
 tigue, etc.) In all these cases there is the same 
 disparity between the afferent and efferent 
 nerve stimuli. This exposition is no mere hy- 
 
 32 
 
pothesis. It rests upon the well-known general 
 recognized property of the ganglion cells to 
 accumulate impulses and discharge them ex- 
 plosively though we have as yet no further ex- 
 planation. It suggests a fundamental charac- 
 teristic of nerve power which is a physiological 
 observation. This brings us to a closer under- 
 standing of the different types of physiological 
 tremor. 
 
 As has been stated previously, as a result of a 
 careful study of the various irregularities that 
 appeared upon our cardiograph records and 
 finding that many of these finer movements 
 were due to tremors, a more careful study of 
 tremors was commenced, and soon the necessity 
 was apparent of an apparatus that would 
 graphically record the various movements of 
 tremors. It was desired that this apparatus 
 should be small and compact and capable of 
 being used by the physician in general practice. 
 Fig. 13. As a result of experiments, the 'writer 
 presented the Tremograph, 60 Fig. 1 (L. S.), 
 and demonstrated its use at the Minnesota 
 State Medical Society in the fall of 1916. This 
 apparatus is used in conjunction with the re- 
 cording apparatus of the modified McKenzie 
 Polygraph (B) 53 , and gives a light, compact ap- 
 paratus for making definite accurate records 
 of tremors and clonus in a permanent form and 
 with the time element portrayed, Fig. 14 
 
 The Tremograph consists of two tambours 
 (E) set at right angles, so placed that one is 
 vertical and the other horizontal to the axis 
 of movement. These tambours are connected 
 with the tambours of the modified McKenzie 
 polygraph by rubber tubing. (G). The move- 
 ment to be recorded is accentuated by the plac- 
 ing of spring vibrators of steel wire (H) in 
 front of the tambours. Metal olives (F) with 
 
 33 
 
Fig. 13. Tremograph. 
 
 screw adjustment to permit their being placed 
 in different positions along the spring vibrators, 
 increase the oscillations and give a marked 
 record of the vibration. Various handles are 
 used which permit the securing of different 
 types of records. These can be screwed on to 
 the apparatus and are used for securing 
 records of different parts of the body. (A). 
 Plain round handle (C) ordinarily used and 
 held in either hand. (B). The tonometer (D) 
 with screw socket placed on one end which per- 
 mits the apparatus being used for securing 
 pressure tremors. (C). The slightly curved 
 plate 2"x3" with two straps and buckles that 
 permit placing it immovably on any part. This 
 is especially used for tremors and used princi- 
 pally on the lower extremities. 
 
 In order to secure analogous records of pa- 
 tients under similar conditions, the following 
 procedure is adopted. The patient is made as 
 comfortable as possible, whether seated erect 
 in a chair or in bed. If in a chair, the feet 
 should be flat on the floor and the hands on the 
 knees. The handle of the Tremograph is then 
 placed in one of the patient's hands and held 
 between the thumb and extended forefingers, 
 the horizontal arm to the front. The patient is 
 then instructed as to the motion to be made 
 with the instrument. The following move- 
 ments have been used by us in securing records 
 
 34 
 
as" being representative of all voluntary move- 
 ments. 
 
 1. "R.T." (Rand L) "Best Tremor ". This 
 record is secured by having the patient raise 
 the hand from the position on the knee, (a) 
 front and upward to full extension of arm, (b) 
 then holding arm at full extension, (c) then re- 
 turning to knee position. These movements are 
 made in a definite time five seconds to each 
 move or position, the rate of movement being 
 indicated to the patient by the operator's arm. 
 This is of advantage, as the attention of the pa- 
 tient is focused and any uneasiness relieved. 
 
 2. "P. T." (R and L). Pressure Tremor, 
 same as Rest Tremor only tonometer is used as 
 handle and held gently, arm raised (1) then at 
 full extension, (2) the patient compresses han- 
 dle to limit, then at (3) releases to gentle grip 
 and return to knee. Record is made on slip of 
 the grip pressure. 
 
 3. "F.N.T." (R and L) Finger Nose Test. 
 The round handle (A) as used in (1) the move- 
 ment consists of four positions, each occupying 
 five seconds as in (1), (a) knee to full exten- 
 sion, (b) then elbow is bent bringing the instru- 
 ment, still vertical position, close to nose, then 
 (c) back to full extension and (d) back to 
 knee. 
 
 4. "R. T. Leg." (R and L). The metal pad 
 (C) used and attached to top of foot. Each 
 foot is brought up (a) to full extension, (b) 
 held, then (c) returned to floor. 
 
 5. "F. K. T. of Leg." (R and L). Foot Knee 
 Test. (C) attachment as in (4) movement (a) 
 to full extension, (b) foot brought close to oppo- 
 site knee, (c) back to extension and (d) back 
 to floor. 
 
 This produces a series of tracings which 
 cover practically all the common movements. 
 
 35 
 
Fig. 14. Records of Tremors: 
 
 a. Exophthalmic Goitre. 
 
 b. Exophthalmic Goitre. 
 
 c. Chronic Lenticular Degeneration. 
 
 d. Multiple Sclerosis. 
 
 Tremors of the tongue may be tested by a 
 little aluminum clip attached to one of the 
 spring vibrators, and the tremograph attached 
 to some solid object. The tongue is placed on 
 the aluminum clip. For coarse tremors a 
 smaller sized metal olive is used which produces 
 a narrow oscillation of the writing lever. 
 
 In eliciting tremors by the older methods 54 
 "to distinguish between passive tremor 
 and intention tremor, direct the patient to 
 make some movement such as taking up and 
 fastening a collar button, buttoning a vest, or 
 drinking a glass of water. In this latter variety 
 the tremor is greatly increased by the co-ordi- 
 nate movement involved and indeed may be 
 wholly absent when the patient is at rest. By 
 resting the tips of the patient's fingers (Quin- 
 quad's phenomenon) upon the palm of the 
 hand, a vibration otherwise imperceptible may 
 be readily detected." This is the usual form of 
 noting tremors by clinical methods. Though 
 
 36 
 
this does not give a definite estimation of the 
 rapidity or the strength of the tremor, still 
 with a careful observation by this method the 
 clinician was able to determine whether the 
 tremor was fine or coarse. 
 
 Many types of apparatus have been used to 
 estimate and record graphically the various 
 forms of tremor but all of them were cumber- 
 some and complicated for common use. 
 
 Warner 55 , in the early eighties, brought out 
 interesting but complicated apparatus consist- 
 ing of an arrangement of rubber tubes, one for 
 each finger, and each leading by the piece of 
 tubing to an elaborate apparatus with a smoked 
 drum, the frame supplied with recording tam- 
 bours and electric signals. By means of this 
 apparatus he brought out some interesting fig- 
 ures on the movements of the hand and its 
 various parts. 
 
 Various other devices were used and much 
 valuable data has been gathered by 56 Grashey, 
 Schafer, Peterson, Horsley, Wolfenden, Ewald, 
 Gowers and Dana. Peterson 57 , in 1894, pub- 
 lished very interesting results of exhaustive 
 work on tremors. From these records A. E. 
 Hennely of the Edison laboratory constructed 
 a very interesting geometrical chart of the re- 
 corded waves. In his summary Peterson says 
 " Compared with the kymograph, the sphyg- 
 mograph is coarse, crude and uncertain in the 
 reproduction of various tremors. Most tremors 
 can be placed in two categories fine, from 10 
 to 12 per second: and coarse, from 7 to 8 per 
 second, corresponding to the normal innerva- 
 tion rhythm as determined by Horsley and 
 Schaefer 58 . A slight tremor with normal in- 
 nervation wavelets which are fused in groups 
 of two gives the rate of 5 per second." 
 
 37 
 
In a study of tremors by Neustaedter 59 in 
 1909, he brought out a new type of apparatus. 
 By means of this apparatus a careful study of 
 various types of tremors was made in some 600 
 cases of pathological type. His conclusions are 
 as follows : "1. I want to say that the difference 
 between different tremors are of kind, not of de- 
 gree, and each form of tremor is distinctive of a 
 form or group of diseases." 2. No definite re- 
 lation exists between one form of tremor and 
 any other. 3. The frequency of movements 
 has no bearing upon the character of the 
 tracing. 4. There is no material difference be- 
 tween the movements of the two sides of the 
 body." 
 
 CONCLUSIONS. 
 
 1. Graphic records of reflexes, clonus and 
 tremors may be secured 
 
 a. By means of the string galvanometer, 
 
 b. By means of apparatus recording move- 
 ments of the regions involved, i. e., mechanical 
 action. Such records may be designated broad- 
 ly as reflexograms. 
 
 2. Graphic records of reflexes may be secured 
 showing the form of electrical and mechanical 
 response and also time elapsing between 
 
 a. Stimulus and electrical response in muscle. 
 
 b. Stimulus and mechanical response of 
 parts. 
 
 c. Electrical and mechanical responses. 
 
 3. In the normal reflexogram two elements 
 are found : 
 
 a. An initial deflection of short duration 
 probably a definite reflex response. This ap- 
 pears to be present only in the records of elec- 
 trical response. 
 
 38 
 
b. Definite responses due to muscular action. 
 These show both in the records of electrical and 
 mechanical response. These responses may be 
 reinforced, e. g., by Jendrassik's method, or in- 
 hibited, e. g., by psychic factors, producing 
 probably a state of tension or resistance in the 
 muscles involved. 
 
 4. Tonus plays an important part in the re- 
 flex act. Modifications may be due to an ab- 
 normal state in the afferent or efferent 
 segments of the reflex arc and to conditions 
 above the reflex arc. 
 
 5. In the reflexograms from abnormal indi- 
 viduals, the records may show modification of 
 the reflex response (diminution, exaggeration 
 or perversion) due to altered conditions from fa- 
 tigue, drugs and pathological conditions in the 
 reflex arc and in the upper neurons. 
 
 6. These records are so consistent, definite 
 and permanent as to have a medico-legal value. 
 
 7. Irritability may be increased, in varying 
 degrees and when this is sufficient, clonus may 
 be produced. Clonus records show rate, am- 
 plitude, duration, response to increase of pres- 
 sure by the manipulator, and fatigue. 
 
 8. Records of tremors show rate, rhythm and 
 amplitude. Tremor occurs in normal individu- 
 als and in them is increased by voluntary 
 movement. Tremor is modified in individuals, 
 otherwise normal, by such factors as toxic 
 states, fatigue and drugs. In abnormal indi- 
 viduals alterations in rate, rhythm, amplitude 
 and effects of voluntary movement are re- 
 corded. 
 
 39 
 
BIBLIOGRAPHY. 
 
 1. Hail, Marshal. History of Med., Davis, '03. 
 
 2. Miller, J. H. (1809). Ibid. 
 
 3. Brachet, Ibid. 
 
 4. Bell, Sir Chas. (London). Ibid. 
 
 5. Morton, George (Phil. '39). "Grama Americanae." 
 
 6. Magnedie Floures (Barker). 
 
 7. Smith. H. H., (Barker). 
 
 S.Westphal and Erb., Arch. f. Spychiartrie, Vol. V, 
 1875, p. 792. Berl. Klin. Wochen., '81, Vol. 18. 
 Ibid., '78. 
 
 9. Fiirbringer, Centralblat. f. med. Wissenschr., 1875, 
 p. 929. 
 
 10. Rosenthal and Mendelsohn, Monatschr. d. Roiiiel 
 
 Akadem. su. Berl. Feb. '73. Konigl. Preuss 
 Akad. Berl., '82, '83, '85. Neur. Centralblat. '97, 
 p. 878. 
 
 11. Gad and Flateau, Neurol. Centralblat, 1896, p. 147. 
 
 12. Sherrington, Phil. Trans. Roy. Soc. Lond., 1898, 
 
 p. 136. 
 
 13. Margulies, Wien. klin. Rundschau, 1899, pi. 925. 
 
 14. Turner, Stewart P.: J. N. and M. Dis., June, 1902, 
 
 Vol. 29, No. 6, p. 321. 
 
 15. Buchanan: Jour, of Physiol., Vol. xx, p. 95-190. 
 
 Ibid. Vol. vxi, p. 384, 1899. 
 
 16. Waller, A. D.: Lancet, 1881, Vol. 2, p. 83. Jour, of 
 
 Physiol., Vol. vxi, 1890, p. 384. Brain, 1880, p. 179. 
 
 17. Lombard: Inter. J. M. Sc., 1887, p. 88. 
 
 18. Sahli: Treatise on Diagnostic Method of Examina- 
 
 tion, 1914. 
 
 19. Jendrassik: Beitrage zur lehre vor den Schneu- 
 
 reflex, A. F. K. M., 1883. 
 
 20. Lombard: Loc. Cit. 17. Also, Jour. M. and N. 
 
 Diseases, Feb. 1890. 
 
 21. Bodwitch and Warren: Bost. Med. and Surg. Jour., 
 
 May 31st, 1888. Journ. Physiol., Vol. xi, 1890, 
 p. 384. 
 
 22. Waller: Loc. Cit. No. 16. 
 
 23. Lombard: Loc. Cit. No. 17. Also, Jour. Med. Sc., 
 
 Jan. 1887. 
 
 24. Lanfanauer's method (Sahli). 
 25*. Schonborn's method (Sahli). 
 
 26. Phelps, R. M.; N. W. Lancet, St. Paul, Vol. xil, 
 p. 399. 
 
 40 
 
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 42 
 

 
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