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Transcript of DEFENSIVE REFLEXES.
able that, in connexion with hydatid cyst of the
.spleen the curing of the cyst has been followed bythe disappearance of the associated signs, particularlypolycythaemia, which has never been observed after.splenectomy in the course of a case of true erythro-.cythaemia. Moreover, the study of these secondarypolycythaemias has not been followed sufficientlyfar. It would indeed be very interesting, and it is.quite possible that the polycythaemia can be explainedby a stimulation of the spleen caused by a primarylesion and the production in that organ of abnormalcentres of myelomatosis. In this connexion, one
.must add that the existence of such centres are not-rare in erythrocythaemia. The author has con-
tributed on this subject sections from a recent autopsyin which it is easy to recognise at the level ofthe Malpighian bodies eosinophile myelocytes withbilobular nuclei, primal elements which one knowsto-day may derive their origin from other cellulardements, belonging either to the white or red groupsof corpuscles. This fact, if it were definitely proved,would establish clearly the connexion between trueerythrocythaemia and the polycythsemia secondaryto an affection of the spleen. In the present stateof our knowledge it is permissible to’ suggest thaterythrocythaemia is a specific disease of definiteentity, as Vaquez and Osler declared in their originalobservations.
There remains the question of treatment, a questionwhich is very unsatisfactory up to the present,because the disease goes steadily to a fatal ending,but perhaps recent researches allow us to look forwardto a more hopeful result. Radiotherapy has givencertain satisfactory results, and this line of treatmentis worth careful consideration. If one believes theobservations reported by several authors, particularlyby LÜdin and Beclere, the irradiation of the bones,especially in the region of the epiphyses, producesa considerable diminution, sometimes for a longperiod, in the red cell count, and a diminution, also,if not a complete disappearance, of the subjectivesymptoms. In one of our cases such a result wasobtained, and we have concluded from these facts,as we stated in a paper presented to the Académiede Médecine, that rontgenotherapy is the only measureof any use in combating erythrocythaemia. This isstill our opinion. It must be thoroughly understoodthat the application of the X rays should be madeexclusively over the bones, because when they are
applied over the spleen they can only have the sameunfortunate effect as splenectomy-that is to say, thedestruction of the erythrocytolytic function of theorgan.
In spite of the good results recorded, however, Iam afraid that radiotherapy can only arrest butcannot cure, and can do nothing but hold the poly-cythaemia in check. It is the same in the case ofleukaemia, and is one proof the more of the justiceof the conception of Aubertin, who places these twodiseases in a common group-typical myeloxriatosis ;leukaemia being a myelomatosis of the leucocytesand erythrocythaemia a myelomatosis of the red cells.
BY PROF. BABINSKI.
Prof. Babinski said that the term " defensivereflexes," chosen as title of his lecture, had beenemployed for a considerable time and was usefulsince it did not imply any definite hypothesis as to themechanism of the motor reactions described under thiscategory. He then proceeded to describe these motorreactions, discussing first those which are producedin the stimulated lower limb, excluding reflex move-ments of the toes. He discussed the resemblancebetween pathological and physiological reactions,giving as criterion of pathological defensive reflexesthe reflex flexion of the foot elicited by stimulation of thefoot or leg, -exclusive of the plantar region. -- Theimportance of this sign in neurology is that it is
easy to demonstrate, is frequently present, andreveals a lesion of the pyramidal path. The closeconnexion between this sign and the Babinski toe-phenomenon (reflex extension of the toes, especiallythe hallux, together with reflex abduction of the toes)is clear, the one completes the other. As regards theirmode of production, they would seem to have a
common pathogenic origin though one may be presentwithout the other. In certain cases, admittedly rare,the presence of a pyramidal lesion may be revealed bythe presence of reflex flexion of the foot, even when theextensor toe-phenomenon is absent.
Prof. Babinski traced the connexion between theforegoing phenomena and the exaggeration of thetendon reflexes, which also constitutes a sign ofdisturbance of the pyramidal path. In cerebralhemiplegia, exaggeration of the tendon reflexesmay coexist with feebly marked defensive reflexes ;sometimes the converse occurs at the onset of a
hemiplegia. In spasmodic tabes dorsalis (Erb-Charcottype), where the tendon reflexes are very brisk, reflexflexion of the foot may be feeble or absent. On theother hand, in Friedreich’s ataxia the abolition of thetendon reflexes is in marked contrast to the intensityof the defensive reflexes which is often noticeable.The same contrast occurs in ordinary tabes whenassociated with a pyramidal lesion. In scleroticlesions of the spinal cord it is common to observe theBabinski toe-phenomenon and the defensive reflex ofthe foot coexisting with tendon reflexes of moderateintensity. In spastic paraplegia " en flexion," wherethe defensive reflexes attain their maximum intensity,the tendon reflexes are sometimes exaggerated, butmay also be normal or even much diminished. The
reflexogenous zone may be more or less widespread,and may extend to the abdomen and thorax. Incertain cases its upper limit corresponds to the lowerlevel of a spinal compression. This fact affords usinformation which, taken together with the level of theanaesthesia, may be of diagnostic value in localising theposition of an intraspinal tumour.Another problem discussed by Prof. Babinski was
the difficult question whether the intensity of thedefensive reflexes is proportional to the intensity ofthe lesions. Does it depend on their situation, or ontheir nature ? Generally speaking, the defensivereflexes are more marked in spinal than in cerebrallesions, perhaps because the former are ordinarilybilateral, whereas the latter are usually unilateral.Following total trans-section of the spinal cord, aftera period of shock, more or less prolonged, the defensivereflexes may become very marked, at least for a shorttime ; but, in Prof. Babinski’s experience, spasmodicparaplegia " en flexion " (termed by certain authorsparaplegia of the Babinski type-where the defensivereflexes, extremely marked and persistent, are
associated with a fairly obstinate contracture) appearsto be associated with lesions which are not accompaniedby marked secondary descending degenerations, oreven show no secondary degenerations whatever.Defensive reflexes, even when well-marked andassociated with severe motor disabilities, do notnecessarily signify that the malady is incurable.Thus in some cases of tumour a cure is obtained,with return of the reflexes to normal. In some casesdiminution of the defensive reflexes may be takenas a favourable prognostic sign. But in other cases(of total transverse lesion) their diminution after aprevious exaggeration may presage the intensifi-cation of the malady and may be a terminalphenomenon.
Speaking of the study of total transverse lesionsof the spinal cord, Prof. Babinski referred to crossedreactions, and discussed the question whether thereare any characteristics indicating that the spinalcord is completely severed. The study of the defensivereflexes during artificial sleep had yielded interestingresults. He compared spastic paraplegia " en exten-sion " with spastic paraplegia " en flexion," and thetwo varieties of contracture termed by him " tendino-reflex " and " cutaneo-reflex " respectively. Indiscussing the views of English neurologists in
certain vexed questions, he quoted the words " pastoujours du meme avis, mais toujours bons amis I "A few words on defensive reflexes in the upper limb,
and a brief rapid summary of certain motor reactionsstudied by Jarkowski and the lecturer under the nameof hyperalgesic reflexes (automatergie), which theydifferentiate from the defensive reflexes, concludedan admirable address, the main points of which wereclearly brought out by lantern slides and demonstra-tions on patients.
Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH.
THE Census enumeration gave a population of 76,508on the night of June 19th, 1921, but the Registrar-General has made an adjustment for holiday move-ments and estimates the mid-year population of 1921at 77,800. Dr. F. T. H. Wood, in his annual report for1921, tells us that the death-rate, 12’98, and the infantmortality-rate, 96, were the lowest ever recorded inBootle. There was, however, an increase in the" diarrhoea " deaths. Fifty-five children died fromthis cause under 2 years of age, giving a rate of 26-6per 1000 births in Bootle, to be compared with 15-5for England and Wales. The birth-rate was 26-58.The death-rate from tuberculosis was high in 1921,1-47 from pulmonary tuberculosis and 1-80 from allforms. There has been a rise in each of the last twoyears and Dr. Wood attributes this to the greateramount of unemployment and the large amount ofcasual labour in Bootle, but he does not give us therates among males and females separately. Dr. Woodgives reasons for thinking that the post-war increaseof venereal diseases reached its highest point aboutthe end of 1919. One in every three cases ceasedattendance before completion of treatment.Owing to unemployment there has been an increase
in the amount of dried milk supplied under the MilkOrder, but Dr. Wood is satisfied that this relief hashad good results in the prevention of the infant sicknessand death formerly associated with long periods ofindustrial distress. Thepathologicalexamination of thefoetuses of still-births has led to the discovery andtreatment of several cases of venereal disease in theparents. Seventy-six municipal houses have beencompleted during the year. The housing committeehave had 1167 applications from Bootle residents :in 212 instances the applicant and his family lived inone room and in 463 instances ill two rooms. 102houses have been completed, and 200 have been begun.The original scheme provided for 594 in addition, but,under instructions from the Ministry of Health, thescheme now stands suspended on the completionof the first-mentioned 302 houses, though more aresorely needed.
jR«MS.’7<7.Dr. W. J. Bannister, in his annual report for 1921,
gives some of the principal statistics as follows :Estimated population 30,080, rainfall 10-91 inches.sunshine 1998-5 hours, birth-rate 21-39, death-rate13-3, and infant mortality-rate 82. Scarlet fever of amild type and diphtheria of a rather severe type wereprevalent during the year, the latter causing a death-rate of 0-43 as compared with a rate for England andWales of 0’12. The hot dry summer affected thEdiarrhoea-rate under 2 years, which was 31-2 per 100(births as compared with 15-5 for the whole countryDr. Bannister refers to the unsatisfactory arrangementby which the borough midwives are supervised by thfcounty. The report on the administration of the SalEof Food and Drugs Act shows that very inadequatEpenalties are imposed for the adulteration of milkNo houses were erected under a municipal seltein(during the year and only 20 by private enterpriseThe overcrowding continues.
The school report shows that a good rearrangementhas been made, by which each nurse will carry out allthe health visiting, school, and infant welfare workin her area, and thus come to have a better knowledgeof the families. Of the nine schools only two are"
provided " and Dr. Bannister has much to say aboutthe unsatisfactory condition of the " non-provided "schools as to lighting, ventilation, and equipment, andthe inconvenient arrangements for medical inspection.A dental scheme has been in operation since December,1919. Most of the cases of "toI1sils and adenoids "
have yielded to dental treatment, breathing exercises,&c., without the need for an operation. Out of 148children requiring treatment, only 19 were operatedon. Few facilities exist in the borough for the treat-ment of children with crippling defects.
During 1921 Eastbourne had 2064-8 hours of brightsunshine and a rainfall of 15-79 inches, the latter beingonly about half the average. It was certainly unfor-tunate for the accuracy of statistics, especially forthe health resorts, that the Census had to be taken inJune. The Census population of Eastbourne was62,030. The Registrar-General, however, after deduc-tion for visitors,only allots 53,600 persons to Eastbournefor statistical purposes. On this basis Dr. W. G.Willoughby, according to his annual report for 1921,thinks this is an underestimate; the birth-rate is14-8 and the death-rate 11-9. He strongly recom-mends the council to endeavour to get more housesbuilt. The council has provided 178 houses and has33 in hand. The infant mortality-rate was 75’4.There is a very complete maternity and child welfarescheme. Dr. Willoughby tells us that the opening ofthe Infants’ Hori.-ie removed the necessity for boardingout. which had become increasingly difficult to arrangeat a reasonable cost. A home help, at a salary of30s. per week, did very useful work during the year.There is one firm supplying " Grade A Certified " milkill Eastbourne. The Sale of Food and Drugs Actreport shows that of 92 samples of whole milk taken11 were found to be adulterated. Dr. Willoughbyremarks: "Many samples contained too much dirt,but in the present state of the law, it is not an offenceto sell dirty milk."
CONTROL OF VENEREAL DISEASE.
renereal Diseases in Victoria, Australia.WE have received from Sir James Barrett, the
President of the recently-formed Victorian Branch ofthe Australian Society for Fighting Venereal Disease,a detailed account of the Venereal Diseases Act ofVictoria and its method of administration. He statesthat with two or three minor drawbacks this Act isadmirable as far as legislation goes. Its administrationhowever, leaves a good deal to be desired owing tolack of adequate funds. The Act is administered bythe chairman of the Health Commission, Dr. Robertson,who has under his direction a venereal diseases clinicfor men. The Government has built quite a suitablebuilding for a venereal diseases clinic for women, whichis administered by the staff of the Queen Victoria Hos-pital for Women. Furthermore, an excellent venerealdiseases clinic has recently been established at theMelbourne Hospital by the action of the Red CrossSociety through the late Governor-General of Australia,Viscount Novar, and also with the help of privatebenefactors. The Government, while helpful in thisand in some other matters, has not yet appointed acommissioner or amended the Acts as recommendedin the report on the legislation relating to venerealdisease and the working of the Act, presented to thePremier of Victoria by Sir James Barrett and MajorW. T. Condor.1 By the courtesy of Dr. Robertson,Sir James Barrett has been able to furnish the follow-ing particulars showing exactly what has been done
1 THE LANCET, 1922, i., 384.