Brain Vol. 127 No. 10 © Guarantors of Brain 2004; all rights reserved
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From the archives
Cambridge
The reflex functions of the completely divided spinal cord in man, compared with those associated with less severe lesions by George Riddoch, MD, Temp. Capt. RAMC. Medical Officer in Charge, Empire Hospital for Injuries of the Nervous System, London. Brain 1917: 40; 264–402.
Riddoch's aim was to settle the matter of whether the isolated spinal cord retains reflex activity and, if so, thereby mimics the ‘spinal animal’. His paper is based on eight cases with complete spinal transaction confirmed surgically. Riddoch sets out his stall by summarizing the literature prior to 1917. He adopts the position of Charlton Bastian (1890) and Charles Sherrington (‘The Integrative Action of the Nervous System’, 1906), and is much influenced by John Hughlings-Jackson's writings on the clinical features of spinal cord injury—partial and complete—at various stages after the insult. Chapter II describes (over 24 pages) the circumstances, and the evolution of motion, reflexes, sensation and sphincter control in Lieutenant M., aged 28, wounded by shrapnel on August 6, 1916 and examined, after evacuation to the Empire Hospital, in meticulous detail on 30 occasions over the next 325 days by Riddoch and (occasionally) Dr Henry Head. In a crucial next chapter, against the background of case No. 1, whose body ‘seemed to be cut in two the moment he was shot’, Riddoch reconciles ambiguities in the literature by charting the three stages of spinal cord injury: first, the immediate phase of flaccidity and paralysis; then, the appearance of reflex activity with flexion and extension components, the composite response elicited by genital stimulation, behaviour of the bowel and bladder, and hyperaesthesia at the border between normal and altered sensation; and, finally, the gradual loss of reflex activity following recurrent infection that re-capitulates the initial phase of spinal shock until ‘all signs of reflex action ceases, tone in the sphincters disappearing last; wasting becomes extreme, till ultimately the bones are covered with little more than unhealthy skin which sloughs with slightest pressure and the patient dies’. (The remaining six case records are included as an appendix to the paper.) By comparison with these soldiers whose spinal cords were transected, additional cases (not described in detail) with partial injuries were associated with reflexes mimicking the process of stepping, and showing extensor responses to pressure on the soles or sensory stimulation—a movement rather than a spasm. In seeking a physiological synthesis, Riddoch considered many aspects of the afferent component of these reflex functions, speculated upon features of the intra-medullary components of the reflex arc and the differential dependence of particular reflexes on descending control, and considered the adaptive or purposeful basis for these mass reflex activities. Riddoch concludes that the clinical picture previously described as typical of spinal cord injury was imperfect. He reaches 38 conclusions based on his own observations. The first stage is spinal shock with toneless paralysis and no reflex activity. It lasts from 1 to 3 weeks. Next, as reflex activity returns, characteristic responses—showing ‘adaptation to an end’—emerge, especially withdrawal, typically evoked by a noxious stimulus to the sole but produced by stimulation anywhere below the level of the injury. In its most developed form, this second stage manifests as the mass reflex of limb withdrawal, emptying of the bowel and bladder, and sweating. The tendon reflexes re-appear at between 1 and 5 weeks. These features continue until recurrent infections trigger the third stage characterized by gradual failure of reflex functions, and usually culminating in death. By comparison with this picture of paralysis in flexion, the incomplete spinal cord lesion is characterized by paralysis in extension, terms introduced by Joseph Babinski in 1911 and adopted by the 30-year-old Francis Walshe writing in this journal 2 years before Riddoch. Furthermore, the knee jerk differs in that there is a prolonged phase of relaxation in the incomplete lesion. The opportunities available for management were limited, and his studies largely observational, but Riddoch described circumstances that influenced survival and made for more or less satisfactory function of the bowel and bladder, at least during the second stage. Although he could do little to influence outcome, these lessons were carried over to a new conflict, during which another student of spinal cord injury (Sir Ludwig Guttmann working at Stoke Mandeville Hospital in the UK) reconsidered the nature of paraplegia in flexion and paraplegia in extension, and, with the discovery of antibiotics, treated infections, thereby substantially altering the prevalence of Riddoch's third stage.
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