HYGIENE .OF REFLEX ACTION. 
BY 
HENRY LING TAYLOR, M.D., - 
NEW YORK. 
Read at the meeting of the Neurological Section of 
the New York Academy of Medicine, 
held March 9.1888. 
Reprinted from The Journal orNervous and 
Mental Disease, March, 1888. Reprinted from The Journal of Nervous and Mental Disease, March, 1888. 
HYGIENE OF REFLEX ACTION.* 
By HENRY LING TAYLOR, M.D., 
NEW YORK. 
MAN is the only creature that can live anywhere in the 
world. He can make shift to get along on an 
island, a mountain, or a tree-top ; in a cell, a desert, 
or a city. He will live an average lifetime on rice, blubber, 
or clay, and will submit to the most diverse conditions im- 
posed by nature or himself. His pre-eminence in this respect 
is due to the differentiation of the functions of his nerve- 
centres, and the capacity they have acquired for storing up 
energy, which can be drawn upon to meet the vicissitudes of 
his changing environment. The more varied and thorough 
the training and experience of his nerve-centres, the better 
will he be equipped. In every community we see a natural 
elimination going on of individuals who imperfectly adapt 
themselves to the conditions of their lives, and it is with 
those subjects who imperfectly react, whether temporarily or 
habitually, to the stimuli which reach their nerve-centres, 
that the physician has to do. 
Without stopping to describe the special mechanisms by 
which these adaptations are accomplished, and confining this 
discussion mainly to the functions of those cerebro-spinal 
centres immediately concerned in the associated reflex move- 
ments of the trunk and limbs, let us consider in a general way 
the effect upon the individual of their various states and re- 
actions, especially as observed in orthopaedic practice. 
By countless filaments connected with receptive surfaces 
* Read at the meeting of the Neurological Section of the New York Academy 
of Medicine, held March 9, 1888. 2 
HENRY LING TAYLOR. 
and spaces, showers of impressions are constantly pouring in 
upon the centres, some leading to no visible effect, yet not 
without effect, others going to set up changes which are di- 
rectly reflected to the muscles and glands to spur them to 
action, or passed from cell to cell, and all ultimately modify- 
ing in some degree the function of the remotest cell in the 
body. By far the larger portion of these in-streaming stimuli 
are never consciously perceived, but help to form that sub- 
stratum of unconscious life upon which the fabric of our being 
rests. 
There is, therefore, a continuous, unperceived alimenta- 
tion and training of the nerve-cells of the cerebro-spinal axis, 
from the absorption of incoming stimuli and, in many cases, 
their reflection along various paths ; but, important as are the 
impressions received through the special sense-organs, par- 
ticularly for consciousness, it is probable that the innumerable 
afferent impulses from skin, membrane, muscle, gland, and 
other tissues, responsive to changes in temperature and con- 
tact of the atmosphere and the blood, and changes in tension 
and position of the muscles and members, are equally funda- 
mental and important. 
A centre may have its activity re-enforced or interfered 
with by impulses from connected centres, and its function at 
any moment is the resultant of its own activity and all the 
re-enforcing and checking influences which reach it. Certain 
cells become specialized by inheritance or training, so that 
they store up the effect of impressions, giving out their im- 
pulses when properly stimulated. There is thus a selection 
of reflex arcs and paths in the evolution of the organism, so 
that, starting with but few and imperfect ones, many new ones 
are added according to its experience and necessities. 
Reflex actions, as we observe them, are the products of 
the activity of many end-organs, fibres, and cells ; the latter 
connected with neighboring cells of similar grade and distant 
cells of higher function, and through their influence reacting 
to an ever-changing environment. The co-ordination of com- 
plicated movements, to a small degree innate, is for the most 
part painfully wrought out by innumerable repetitions, fail- 
ures, and modifications, until our reflexes become what they HYGIENE OF REFLEX ACTION. 
3 
are. A lady who has preserved the first little shoes of all her 
children tells me they exhibit evidence of the most varied 
use, one pair being worn at the toes, another at the heels, 
and others at the sides. 
This acquirement of definite reflexes, i.e., habits, is in the 
interest of an economy of force, and, once the needful asso- 
ciations are formed, volition is left free to initiate or control 
movements instead of laboriously executing them. "The 
digital struggle and facial contortion " of the youthful pen- 
man indicate the large number of nerve-cells necessarily in- 
volved in such an operation at first. Constant repetition and 
practice enable a much smaller group to do the work infi- 
nitely better, and at a fraction of the cost in protoplasmic wear. 
Talking, singing, playing on instruments, the use of tools, 
etc., and most of our oft-repeated actions, undergo similar 
improvement, to the economy of the organism and especially 
of the master-cells in the brain. 
The reactions of the cord-centres will thus be seen to de- 
pend upon the nature and intensity of the stimuli received, 
so that we have a means of reaching and treating the nerve- 
centres by stimuli properly applied. When these are suf- 
ficiently varied, without being too numerous or too violent, 
the correlated peripheral and central areas readily act and 
react, each arc and group of arcs working out its experience 
and adjustment, until, in the same manner as a man's face re- 
flects his character and experience, his hand or his back will 
acquire a form and expression largely dependent upon its 
neural life-history. Similarly, his carriage and attitude and 
the grace and dexterity of associate movements will depend 
upon previous training of the reflexes. We recognize a sail- 
or or a case of Pott's disease at once from the gait, i.e., from 
reflexes conditioned by special experiences. 
The neural, and, to a great extent, the general vigor will 
depend upon the tonic action of large numbers of adequate 
adjustments and reactions well distributed over the different 
regions of the body. Unfortunately the environment sup- 
plied by our modern city life narrows the experiences of im- 
portant regions of the body while it unduly quickens many 
purely cerebral processes, so that our wits are taxed more HENRY LING TAYLOR. 
4 
than our muscles. Shoulders, chest, back, and loins, and 
with them the thoracic and abdominal viscera, suffer particu- 
larly from our restricted and feeble muscular experiences, 
which lowers the tone of the centres, as in Langley's experi- 
ment on the frog, where "the ordinary reflex action pro- 
duced by the stimulation of one sciatic is diminished by sec- 
tion of the other sciatic" (Foster, p. 605). Many persons, in 
being shielded from the necessity of any sufficient variety or 
vigor of purposeful and useful reflexes, either never emerge 
from, or lapse into, a state of spinal torpor, where the logical 
tendency would be toward a purely vegetative existence and 
the shedding of the appendages, as has already happened 
in some of the Crustacea. Such conditions of torpor from 
" starvation " of the spinal nerve-centres may exist with con- 
siderable cerebral activity of one kind or another-overstim- 
ulation of the brain is apt to depress the tone of the cord- 
which leads to the remark that in practice an uneven or 
vicious distribution of stimuli is more common than absolute 
excess or deficiency. How we do a thing is not less impor- 
tant than what we do and how much. One-sidedness is the 
disease that is killing us. 
In general, the kind of education which the spine and 
brain get from manual proficiency is very solid and very 
wholesome, but this has been much curtailed in the artisan, 
professional, and leisure classes by the excessive monotony of 
impressions from the sudden development of the extreme 
division of labor and use of machinery which characterize our 
modern civilization. We are just beginning to realize that the 
experiences of skin, membrane, and muscle-regions are as 
important and more fundamental than auditory or visual im- 
pressions. One-sidedness tends to overuse of the active re- 
gion, often culminating in strain and exhaustion of the cen- 
tres, which produces a profound detrimental effect, not only 
upon their function but on tissue-metabolism. It would seem 
that for every organism there is a certain range of stimula- 
tion within which it reacts readily and makes easy adjust- 
ments and assimilations. When the stimuli become too in- 
tense, too constant, or too disorderly, symptoms of wear and 
.overwork, a sort of " neural dyspepsia," show themselves in HYGIENE OF REFLEX ACTION. 
5 
the centres, and the nutrition of the body soon suffers, which 
in turn increases the protoplasmic distress in the centres and 
establishes a vicious circle, exceedingly difficult to break up. 
Disturbances of this kind beginning at one pole of the neural 
axis react upon the chain of connected ganglia, sweeping 
forward as a disturbing wave and exploding with peculiar 
violence at the terminal links. Thus among the numberless 
symptoms of brain-tire, debility and irritability of the gen- 
ito-urinary and locomotor apparatus often occur, revealing 
the perturbed condition of the corresponding spinal centres. 
On the other hand, besides disturbed locomotor reflexes, 
states of profound mental depression, with a tendency to mor- 
bid religious notions, fear of suicide, and fear of insanity, at 
times amounting to melancholia, often result from imperfect 
sexual hygiene. 
Health and mental vigor will be best secured by the exer- 
cise and co-ordination of large numbers of reflex arcs in widely 
separated parts of the body, and a rational distribution of 
neural reactions. 
This view will present competitive athleticism, one form 
of one-sided use of the neuro-muscular apparatus, in a less 
favorable light as a health-promoter than has been claimed 
for it by some of its muscular advocates. Dissipation is the 
habitual excessive stimulation of nerve-centres, and will be 
detrimental according to the intensity, frequency, and dura- 
tion of the molecular catastrophe and the grade of the cells 
involved. Thus medicinal, alcoholic, narcotic, alimentary, 
athletic, sexual, social, emotional, intellectual, and all other 
forms of intemperance are included from this point of view in 
one class as physiologically related. 
The recent interesting experiments of Lombard show 
how delicately the knee-jerk reacts to the general condition 
of the body and the state of the centres. While they 
strengthen the view that the knee-jerk is not a true reflex 
act, its force seems to depend largely upon the state of the 
spinal centres, and one cannot help regarding its incessant va- 
riations as in some degree an index of the flushes of proto- 
plasmic activity which there alternately glow and fade. These 
states will depend not only upon the stimuli directly received HENRY LING TAILOR. 
6 
from the periphery, but also upon those retarded impressions 
received from the brain. 
Stimuli projected against a background in the centres ap- 
propriate to the production of painful sensations referred to a 
particular spot, as well as imperfect mechanical conditions, 
will interfere with the usual and normal reflexes of a part. 
Thus unstable footing from any cause, or a pain referred to a 
limb, will modify locomotor reflexes. 
Practically, nothing is more certain than that we can edu- 
cate the spinal reflexes. Persons who have been prevented 
from walking for many months on account of joint-disease or 
other cause have their cerebro-spinal habits very much mod- 
ified, and, on the disappearance of the general or local trou- 
ble, it is found that locomotion is lost or imperfectly accom- 
plished, and largely by direct exercise of the will. Analysis 
of such conditions, with recognition of the cerebral and spinal 
elements, is often necessary, preparatory to establishing a 
more ready and perfect reflex response to locomotor stimuli. 
When the functions of joints or muscles have been inter- 
fered with by disease or design for considerable periods the 
habitual reflex arcs become rearranged ; we say a patient has 
a trick or habit of walking. Instinct is not always a safe 
guide in such cases. There are many cripples and invalids 
who have not acquired the associated movements which 
would enable them to make the most of the limited motion 
in a damaged joint or the limited power in weakened muscles. 
These considerations will apply to many cases among the 
hemiplegics, paraplegics, and paretics, whether from cerebral 
or spinal lesions, in which the vitally important question for 
the patient will be how to get the best service in associated 
reflexes out of his imperfect cerebro-spinal apparatus. The 
fact that the muscles are not sufficiently used, or even the 
circumstance that the accustomed neural paths are not kept 
worn smooth, is not the whole explanation of the difficulty; 
the lack of proper afferent impulses' from sufficient peripheral 
stimulation is in all probability a most important factor. 
Such cord and brain-centres, closely related to the member 
in question, as may still be intact, suffer from the lack of im- 
pinging stimuli and grow lethargic. HYGIENE OF REFLEX ACTION. 
7 
By a careful study and training of such capacity as exists, 
the physician will not only vastly improve the condition of 
these patients but give them the very best chance for increas- 
ing their powers by proper use. There are few cripples 
whose condition after the cessation of disease may not still 
be ameliorated with time and painstaking. 
In the neuro-muscular degenerations following acute an- 
terior polio-myelitis it is especially important to restore to 
the paretic extremities, so far as possible, the stimuli of loco- 
motion and other normal associated movements without the 
inhibition of insecure footing and strained tissues. This 
should be the aim of mechanical treatment in such cases, and 
it is for the specific purpose of restoring to the damaged cord 
and muscles the cutaneous, muscular, and articular stimuli of 
locomotion that our apparatus are constructed. Even in 
mild cases a varus foot or wobbly ankle may produce such a 
sense of insecurity that the gait will be largely cerebral, con- 
sequently imperfect and exhausting, instead of mainly spinal 
and unconsciously performed ; as in trying to walk on a 
slippery place or on rollers the postural reflexes of the knee, 
hip, and trunk-in fact, of the entire body-are rearranged by 
cerebral interference, and the joints held in special relations 
to afford a fixed point for the unsteady foot or to favor weak- 
ened muscles. Normal reflexes of locomotion are broken up 
and a wasteful and cumbersome set installed subject to con- 
stant cerebral interference in the efforts at balancing and 
progression, and additionally disturbed by the strain on 
weakened muscular and joint structures, which is rendered 
inevitable by the lack of balance between opposing groups. 
Thus the foot may be the key to the function and nutrition 
of the entire limb, and even to the health and carriage of the 
whole body. 
Deformity having been overcome and the position of 
election given to the foot with exactness by mechanical sup- 
port, and the direction and amount of motion precisely lim- 
ited according to the indications, the sole is placed evenly 
upon the ground and the ankle held from lateral insecurity, 
so that the normal stimuli of pressure and motion are sent to 
the cord and reflected to the muscles, as well as the central 8 
HENRY LING TAYLOR. 
lesion will permit. This mechanical protection with muscu- 
lar training enables the patient to acquire a better set of re- 
flexes and promotes the nutrition of the part. The special 
vascular paresis of this condition is most successfully cor- 
rected by the stimuli of very hot air locally applied, by means 
of a box heated by alcohol or a gas-jet. 
This is the theory of treatment of infantile paralysis. If 
many reflex arcs are severed this stimulating influence can 
be less perfectly produced, and its effect on the muscles whose 
motor-centres are absolutely and permanently destroyed must 
be largely lost. But the ultimate fate of such muscles is not 
doubtful, and the stimulating influence of correct relations 
and reactions of the locomotor apparatus will be felt in the 
posterior columns, and radiated by them to neighboring motor 
areas and to the brain ; the latter effect is very often marked. 
I.-A little girl, 6 years of age, brought to me in the 
fall of 1886, had been unable to stand or to walk since an 
attack of infantile paralysis three years previous. She had al- 
ways been perfectly content to sit quietly on her mother's lap 
without inclination to talk or to join in the activity around 
her, but on being placed upon her feet and enabled to walk, 
at the end of two weeks, she apparently experienced an en- 
tire change of disposition ; she became talkative, lively, and 
ambitious to join in the plays of the children, and her mother 
had difficulty in restraining her. 
These conditions of treatment cannot be realized without 
the greatest care in the design and construction of apparatus 
and perfect exactness and precision in their application, with 
such progressive changes as may be necessitated by the alter- 
ing indications. If a paralyzed knee or ankle is allowed to 
yield a little from faulty construction or application of the 
apparatus, inhibitory influences are at once excited which in- 
terfere with that symmetrical development of associated re- 
flexes which has been mentioned. While it is not claimed 
that muscles which have absolutely disappeared can be re- 
stored, the plan of treatment above outlined is a rational at- 
tempt to make the best use of what are left, and it is astonish- 
ing how helpless many patients are, whose condition is really 
far from desperate, for lack of a little well-directed assistance HYGIENE OF REFLEX ACTION 
9 
and training. The little girl just mentioned was brought to 
us two years before, and would then have come under treat- 
ment if the mother had not lost confidence by the favorable 
prognosis that the child would probably walk within two 
months. 
II.-This little girl was severely paralyzed, but a boy of 9 
years who came in March, 1886, and had never walked since 
his paralysis in November, 1885, was a case of only moderate 
severity. He had fair power in the right leg and could stand 
on it for a short time ; the left leg was practically helpless ; 
the knee was flexed 35 degrees, and abducted 20 degrees, 
and there was no power in the extensor muscles. There was 
a talipes equinus of 20 degrees at both ankles, as well as a ten- 
dency to valgus. These contractions were stretched by means 
of an apparatus, locked at the knee at the angle of choice and 
extending the entire length of the left leg, and an ankle-brace 
applied to the outside of the right foot with a screw-stop 
for progressively increasing ankle-flexion. These apparatus 
were so contrived as to be capable of progressive modification 
as the boy improved and to serve as supporting braces after 
the deformities were overcome. 
The deformities were entirely rectified by the end of three 
weeks, with the exception of the knock-knee, which was so 
much diminished as to be no longer disabling. This patient 
has been walking freely ever since for considerable distances 
without other support than his braces, and his progress has 
been remarkable in other respects. The left (worst) leg 
gained, in the first year, 1 inch at the top of the thigh, y2 
inch each at the knee and calf in circumference, while the 
right leg gained 1 y inch, y, and y2 inch respectively, the legs 
remaining equal in length. He was then able to walk with a 
free knee-joint and the lock was discarded, although there 
was no return of power in the quadriceps muscle. He could 
also walk very fairly without his braces, and it is, in my opin- 
ion, only a question of a moderate length of time before he 
will be able to discard mechanical support altogether. 
The spasmodic condition of the neighboring muscles, re- 
sulting from the stimuli of the irritated tissues in progres- 
sivejoint disease, presents a condition opposite to the one dis 10 
HENRY LING TAYLOR. 
cussed. We cut off locomotor stimuli, in the acutest cases, by 
putting the patient to bed for a month or six weeks, and elim- 
inate, so far as possible, by counter-extension the specially 
irritating and damaging stimuli occasioned by the rubbing 
and pressing of the inflamed surfaces. When the recession 
of the inflammatory action is fully inaugurated, we allow lo- 
comotion, with the weight borne on the perineal strap of the 
counter-extension splint, which takes the pressure from the 
joint and does not permit the foot to touch the ground, using 
crutches also if necessary. In the recovering stages it is 
desirable to permit a certain amount of stimulation, in order 
to promote nutrition, before the joint can safely bear press- 
ure ; we therefore give thejoint motion, the amount of which 
is regulated by proper stops on a jointed apparatus, which 
still suspends the leg and carries the weight on a perineal 
strap. In this way the amount and kind of reflex stimulation 
which the leg receives is carefully regulated according to the 
indications. The withdrawal of stimulation causes muscular 
weakness and wasting, which is favorable to the joint in the 
active stages of disease, but the muscles improve as the joint 
recovers and the stimuli are readmitted. It is thus seen that 
bracing a paralyzed leg and a diseased one have entirely dif- 
ferent objects and results. 
Variously disturbed and faulty reflexes are a prominent 
and sometimes the paramount factor in many cases of so- 
called " chronic sprains," neuroses of the joints, neurasthenic 
hysteria, sluggish and irritable viscera, imperfect general nutri- 
tion with nervous symptoms and backache, often distinguished 
by the bedridden or partly bedridden condition. This com- 
prises a large and somewhat heterogeneous class of invalids, 
many of whom are exceedingly helpless and very great 
sufferers, whose condition is the logical, we may say the in- 
evitable, result of faulty training of the reflexes, in them- 
selves as well as in their ancestors. Their nervous system, 
and perhaps general nutrition, suffering according to circum- 
stances and temperament from the strain or relaxation of 
imperfect adjustments, affords favorable conditions for the 
formation of local disturbances of reflex action from causes 
sometimes so slight as to escape observation. The neuro- HYGIENE OF REFLEX ACTION. 
11 
muscular machinery is vulnerable, and, given the proper soil, 
the abundant and varied crop of neural disorders easily 
germinates. Take a case of " chronic sprain." The patient 
presents himself to the physician usually with pain and ten- 
derness in the affected part, often with wasting, rarely with 
heat or swelling, though a subjective sensation of burning and 
the puffiness of relaxed tissues are not uncommon. Disa- 
bility of the most varied character and imperfect co-ordination 
of the neighboring muscular reflexes are among the most 
common symptoms, and the most characteristic one is the 
visible though often unconscious accommodation of the re- 
flexes of the entire body to the condition of the disabled 
member. This is equally true of allied neuroses, and it is 
usually more distinct and more widely distributed than the 
secondary reflex adjustments in joint-disease, and somewhat 
different in character, possibly due to greater prominence of 
the cerebral element. If the patient have a lame ankle he is, 
so to speak, " ankle all over ; " if it be a young woman with 
a backache, she presents every evidence in her conscious and 
unconscious life of the paramount influence of that region of 
the body. If we may speak of " care " as referring to atti- 
tude and movements in joint diseases, we may possibly 
characterize as " apprehension" the phenomena referred to 
in these functional troubles. The " care " of a diseased joint 
is most distinctly noticed in distant reflexes when the joint 
is hurt or threatened with violence. Pain, especially in the 
earlier stages of joint disease, is rather paroxysmal in char- 
acter and often absent; the patient frequently forgets his 
trouble and hurts his joint by too spontaneous movement. 
In a neurotic joint affection, pain, while more constant, is not 
invariably a prominent feature, but, no matter what the dis- 
tractions of the patient, the remotest muscular reflexes of the 
body are in a would-be-protective state of apprehension in a 
typical case. This influence can often be distinctly perceived 
in the expression of the face and the tone of the voice as well 
as in the peculiar mental attitude of the patient ; the percep- 
tions, emotions, and intellect will frequently revolve around a 
knee or a back for a centre as plainly as the muscular reflexes. 
So-called " chronic sprains," as I have seen them, usually re- 12 
HENRY LING 7'AYL OR. 
solve themselves into disturbances of the associated reflexes 
about the joint in question, whose starting-point has often 
been a real sprain or strain, but which had long before re- 
covered, leaving disordered neuro-muscular action in its 
wake ; these in turn interfere with the nutrition of the part 
and keep up the pain, which originally may have represented 
a slight organic lesion. 
III.-A gentleman, aged 38, came in May, 1883, to have 
a brace applied to his right ankle, which he had sprained 
three months previously. There was pain and disability from 
the time of the accident. He did not use the foot for four 
weeks, and after that walked lame and only for short dis- 
tances. The examination showed pain and tenderness about 
the ankle, especially the outside, with limited motion and ir- 
regular, spasmodic action of the muscles. Considerable mo- 
tion at the ankle was brought out by finessing, much to the 
patient's surprise, as he could scarcely move it at all when 
told to do so. The diagnosis of disturbed reflexes about the 
ankle-joint without present organic lesion was made, and ed- 
ucation of the reflexes by passive and active movements ad- 
vised and begun. On the third day motion was nearly nor- 
mal, with scarcely any pain, and the patient stated he had 
not felt so well since the accident. Three days later the 
patient was discharged cured, with normal locomotion, the 
movements of the ankle being perfectly natural and under 
control. Eight months after he was reported as continuing 
perfectly well. 
IV.-A lady, about 50 years old, came to me in June, 
1884. She had slipped on a piece of orange peel and turned 
the left ankle two years previously. This accident was fol- 
lowed by pain, swelling, and disability. She walked for the 
first time, six weeks after the accident, and then for a long 
time, from sickness in the family, she was obliged to be con- 
stantly on her feet and suffered from overexertion, anxiety, 
and broken rest. She asserted that pain, heat, swelling, and 
lameness had continued up to the time of examination, and 
had been worse during the previous six or eight weeks. The 
symptoms had been so severe that for a week before coming 
she had used crutches. The patient was a delicate woman, HYGIENE OF REFLEX ACI'ION. 
13 
who had been worn out by mental strain and overexertion. 
She had had milk-leg on both sides several times, and vari- 
cose veins were present. The examination showed no swell- 
ing. She was able to relax the ankle and permit it to move 
naturally in all directions, and also to execute these move- 
ments voluntarily. She said she had never tried to move 
the ankle before, and did not know that she could. It was 
explained to the patient that the ankle was suffering from 
disuse and imperfect hygiene. The crutches were at once 
discarded, and physical, educational, and developmental 
treatment begun. In a week the patient stated that she did 
not know she had an ankle, and was able to lie on the left 
side, which she had not done before. She remained for sev- 
eral weeks for general tonic treatment, and has since been 
seen socially from time to time, and reported that her ankle 
had remained well and that only occasionally, after overexer- 
tion, was she reminded of the accident. 
V.-While passing through Fall River in July, 1884, I 
was called to see a large, athletic young man, 17 years old, 
whose left knee had given out while tramping through Swit- 
zerland six months previously. He afterward limped when 
he tried to use it, and thought that it swelled. He had been 
better and worse by turns, but the knee had never ceased to 
trouble him, and for ten weeks he had walked on a crutch 
and a cane, bearing very little weight on the affected limb. 
Naturally energetic, he felt his condition very much, and 
chafed under the awkward work he made in hobbling around, 
and was exceedingly anxious to be relieved. The left thigh 
measured 1 inch less at the top, 1^ inch less above the knee, 
f of an inch less at the calf, and i inch less over the knee, 
although he believed it to be swelled. Mobility was good, 
and it was perfectly evident that the limb was suffering from 
nothing except disuse. After going through a few passive 
and active movements of the leg in various directions, I got 
him to stand up with his feet flat on the floor, and made him 
bear his weight on both limbs. Inside of five minutes I had 
him walking around the table without assistance, and, to fol- 
low up the impression, I took him a short turn in the street 
and up the front steps of the house. At the end of fifteen 14 
HENRY LING TAYLOR. 
minutes he walked without a limp, and I took my leave of 
the bewildered family. This young man never had any 
trouble afterward, and played on the Harvard team in the 
intercollegiate football match last Thanksgiving. 
VI.-A married lady, 44 years of age, came in May, 
1884. She had suffered a great deal with her left knee for 
30 years. While at boarding-school at the age of 14 her 
knee began to hurt her at times, especially on stepping up, 
but she did not remember to have injured it. She afterward 
met with a number of rather trivial accidents which had laid 
her up for months at a time and obliged her to use crutches ; 
the knee also troubled her sometimes without known cause, 
so that it was often treated locally. Two years before com- 
ing she fell and struck her knee, and since then had used 
crutches constantly and kept the knee bandaged. Aching 
had been frequent and, since the last accident, located on 
the inner aspect of the knee below the patella. The patient 
held her knee in continuous complete extension, as had been 
her habit when it troubled her (I have noticed this peculiar- 
ity, impossible to the sufferer from synovitis, in several cases). 
Her right knee measured 1 inch, and the right calf 1^ inch 
less than the left. She was of nervous temperament, but of 
fair physique and general health, and not morbid. Exam- 
ination showed no organic change in the joint, except that 
incident to prolonged disuse. The knee-motion was of con- 
siderable extent and good quality, but voluntary control of 
the muscles moving the knee was deficient. She could hold 
the knee out when sitting, but not extend it from the flexed 
position. The diagnosis was atrophy of the limb and prob- 
able dryness of the knee-joint from disuse and disturbed re- 
flexes. Graduated passive movements at the knee by special 
apparatus actuated by steam-power were given for half an 
hour daily, and gradually increased in extent and duration. 
She was also drilled in placing the foot squarely on the floor, 
in bending the knee, and in gradually increasing the amount 
of weight borne upon the limb as she walked with the 
crutches. This was followed in a few days by some increase 
of pain and considerable puffiness about the knee, though 
the exercises themselves were not painful. Nine days after HYGIENE OF REFLEX ACTION. 
15 
beginning the treatment she was able to extend the leg from 
the flexed position ; three days later she laid the crutches 
aside, walking readily, though with a slight limp. In a 
month after coming she was able to bend her knee and to 
walk considerable distances without crutches, and the pain 
had greatly diminished. She gained markedly in flesh and 
in spirits, and lost the drawn and anxious expression she had 
had. In five weeks from coming the affected knee had 
gained one inch in circumference and the calf inch, and 
the patient returned to her home. She has since been fre- 
quently reported by members of her family as enjoying per- 
fect health and locomotion. 
VII.-A bright, active, intense woman, 27 years of age, 
came in May, 1885. She had fallen, striking the lower part 
of her left knee, seven months before. It pained her only 
moderately, and she went on teaching as usual, not walking 
much, until two weeks afterward the knee became red and 
swollen, and there was a pricking pain. She was put to bed 
and kept there four months, blisters and iodine being applied 
to the knee. During this time the knee was kept stiffly ex- 
tended, and when she got up it was put in plaster for three 
weeks, and she walked on crutches, with a high sole on the 
right foot. She came on crutches, and had not borne any 
weight on the left leg since she went to bed. She had had 
burning, itching, and aching sensations in the knee, aggra- 
vated by motion, but no sharp pains. The patient's health 
had always been good, and she had had no previous sickness. 
She had felt the effect of her knee-trouble severely, but did 
not think she had lost much flesh ; a few days after coming 
she weighed 97^ pounds. Examination showed that the 
limb was held in complete extension by contraction of the 
quadriceps. There was about 10 degrees of voluntary and 
restrained passive motion, which was not very painful, though 
the patient was apprehensive ; when her attention was dis- 
tracted the motion was somewhat greater. The thigh and 
leg rotated outward when the patient was lying on her back; 
the muscles and even the subcutaneous tissues were very 
much atrophied, and the skin very thin, having the appear- 
ance of being drawn over the bones like parchment. The 16 
HENRY LING TAYLOR. 
measurements were as follows: Above the knee, right, I3§ 
inches; left, 12; knee, right, 13^; left, 12^; calf, right, 12; 
left, 10^ ; there was no evidence of any inflammatory trouble 
in or about the joint, nor of any organic lesion anywhere. 
Diagnosis of restraint and abnormal reflexes following slight 
injury was made and the condition explained to the patient, 
who was then able, with a little preliminary training, to walk 
alone without crutches in a few moments, with only moderate 
discomfort and very little limping. Systematic passive move- 
ments and training of the reflexes were begun at once. 
There was some puffiness and muscular soreness during the 
first few days, -but at the end of two weeks there was very 
great improvement in the condition and nutrition of the leg, 
which had already gained an inch in the calf and lower thigh 
measurements. Five days later she discarded her crutches 
entirely, and there was a gain of 1^ and 1^ inch at the lower 
part of the thigh and the calf respectively, over the first 
measurements. The patient left in about six weeks, with 
perfect motion and good control over the knee, though it had 
not yet attained the strength of the right leg. Her general 
health was perfectly restored, and she had gained, in five 
weeks, /£ pounds. 
With some care on the part of the patient the knee con- 
tinued to improve during the summer, and in April, 1886, 
she called to demonstrate its entire restoration, the legs be- 
ing then equal in size and function. 
VIII.-A little girl, 9 years old, was brought in the fall of 
1882, walking on crutches, which she had used for a year, 
during which time she had suffered from pain in the right 
hip with extreme flexion at the hip and knee. All efforts to 
straighten the leg caused such excruciating pain that they had 
to be abandoned. The muscles relaxed under ether, but on 
recovering from the anaesthetic they became as rigid as be- 
fore. Her family physician had recognized the neurotic na- 
ture of the case, but all of his efforts at procuring relief had 
been completely baffled. She was an excessively intense, 
self-conscious child ; her general health was fair, and she was 
very happy in running around on her crutches and joining in 
the plays of the children. Five months of training, which HYGIENE OF REFLEX ACTION. 
17 
was not directed to the hip, as she was already hyper-con- 
scious of that part, were followed by a complete cure, and 
she went home without pain and walking perfectly. This 
little girl had pain at the hip at long intervals for a consider- 
able time, but she never had any recurrence of the functional 
trouble in that location. 
She was brought to me three years afterward as a bed- 
ridden invalid suffering from backache and extreme mental 
depression. After a long and varied experience, she was 
taken home in an essentially bedridden condition and has 
never walked since. There is no question of any organic 
disease, she is simply floored by her chaotic reflexes. 
IX.-A lady about 40 years of age, the wife of a physi- 
cian, consulted me in September, 1885, about her left shoul- 
der ; she had wrenched it three months before while trying 
to save herself from falling on the stairs. She did fall, and 
bruised herself in several places, but not on the shoulder. 
Her arm was afterward stiff and painful, and she found it 
powerless at the shoulder and elbow; she carried her arm in 
a sling, and it had been treated electrically. At the time of 
the examination there was pain in the elbow when she raised 
the arm ; she could not raise the hand to the face nor abduct 
the arm more than 45 degrees from the side. When passive 
movements were made the muscles about the shoulder re- 
sisted, and motion was not free. Diagnosis-of restraint and 
disturbed reflexes. Training of the reflexes by systematic 
movements was followed by marked improvement in mobil- 
ity and usefulness of the arm, but after being treated for a 
week the patient was obliged to leave and went home with 
the arm still very much disabled. It remained in about the 
same condition until the death of her husband, which occurred 
unexpectedly a few weeks later. The shock was so great 
that she became entirely unconscious of her arm, and from 
that time it has been perfectly normal in every respect, as she 
was able to prove to me at her next visit. 
Cases similar to the above are of very frequent occurrence 
in our practice. I recently saw a gentleman who had walked 
with the toes and inner border of the foot elevated for nine 
years, without organic lesion. Some time ago a lady reported 18 
HENRY LING TAYLOR. 
who had walked many years with her toes voluntarily digging 
into the ground at every step. Only a few weeks ago I saw 
a lady in whom a rather severe injury to one finger had been 
followed by disturbed reflexes of the arm. I have under my 
observation at the present time a young lady in whom weak- 
ness of the knee from relaxed ligaments caused such severe 
pains across the back and down the thighs, and so much dis- 
ability, that there seemed to be hesitation on the part of the 
patient and of her father, who was a physician, in accepting 
the diagnosis of disturbed neurility from knee-strain alone. 
Avoidance of locomotion for a few weeks caused an entire 
disappearance of pain in the back. Such instances might be 
indefinitely multiplied. I see more cases of functional joint 
troubles than of joint diseases ; they are exceedingly common 
in this country, and the importance of carefully differenti- 
ating between the two conditions can hardly be exaggerated, 
as many of these functional troubles will be indefinitely pro- 
longed, with great distress and harm to the patient, unless 
recognized and properly treated. 
I have already referred to the fact that there is a wide 
range of disturbance even in those cases where local trouble 
predominates. Not a few, beginning with a local disorder, 
degenerate into a condition of general invalidism, with scarce- 
ly any normally adjusted reflexes, as in the case of the child 
bedridden at thirteen. This is more apt to happen when 
the main disturbance is in the trunk, back, or viscera-of 
course, the primary and essential trouble lies in imperfect ad- 
justments of the higher cerebral centres in a very large num- 
ber of cases, but that element only enters incidentally into 
this discussion. 
X.-A little girl, 12 years old, an only child, was brought 
in May, 1884; she had always been delicate and the object 
of great solicitude on the part of her parents. She had suf- 
fered at various times from chills and sick stomach ; the last 
time in November, 1883, when these symptoms, with pain in 
the back and jaundice, followed a fall. She had been allowed 
to walk but very little afterward, and, as she continued to 
complain of her back, caries of the spine was suspected and 
an apparatus applied, which she still wore. She was pale and HYGIENE OF REFLEX ACTION. 
19 
thin, with an expression indicating solicitude, and was carried 
from the door to the office in a chair. It was perfectly evi- 
dent that the entire family, including the sufferer, were in- 
tently engaged in watching for the development of expected 
symptoms. Examination of the spine showed it to be quite 
normal, with the exception of a slight bending occasioned by 
the shortness of one leg from asymmetrical growth of the 
extremities. Diagnosis of reflex debility, the effect of " too 
much mother," was confirmed by the rapid improvement 
which followed separation from the parents. Gentle exercises 
calculated to give tone to the cord and develop the associated 
reflexes of the trunk and limbs were given, and, the burden 
of constant repression and restriction being removed, it was 
a pleasure to see the pale, sad child taking her first taste of 
natural childhood. On the ninth day she walked two miles ; 
on the tenth she walked upstairs for the first time, an effort 
which the spinal neurasthenic instinctively avoids. In three 
weeks from coming she was riding on horseback, and at the 
end of two months she returned home in perfect health. I 
am confident she would have suffered a relapse had we not 
undertaken the education of the parents, who had become 
completely demoralized by the abnormal relation to an only 
child, and who were trained with difficulty not to watch nor 
repress her. She returned for inspection in five months, 
natural and well in every respect, and having gained consid- 
erably in weight and height. 
XI.-In May, 1886, a gentleman, 28 years old, who had 
always been rather delicate and had broken down at college 
five years before, came with a variety of complaints, of which 
backache and general debility were very prominent. He had 
not been able to do any work since leaving college, and had 
been growing steadily worse, until he was unable to sit up 
for his meals, and even talking made his back ache unbear- 
ably. Pain and apprehension, with introspection and mental 
and physical demoralization, made him a helpless wreck. 
The attempt was made to tone up the centres and restore the 
equipoise of the various functions by properly directed exer- 
cises. He proved a difficult case, but the attempt was so 
successful that he was able to leave for home comparatively HENRY LING TAYLOR. 
20 
restored at the end of two months. I continued to advise 
him by letter from time to time after the discontinuance of 
the treatment, as is my invariable custom in such cases. The 
following fall he took a position as civil engineer with a field- 
party, which he has held creditably ever since, and when I 
saw him a few months ago he was a perfectly healthy young 
man. 
XII.-A case similar as to the general condition, ap- 
proaching the bedridden state, with excruciating pain in the 
back, great prostration, disinclination to exertion, and abnor- 
mal reflexes of the back muscles, was that of a young lady 
who came to me in February, 1886. The pain was so great- 
"as if her back would break in two," she expressed it-that 
it had led to the diagnosis of Pott's disease, and the applica- 
tion of a plaster jacket, which she was still wearing. In spite 
of the protest of the patient, for her reflexes had accommo- 
dated themselves to the rigid casing, the jacket was at once 
removed and the usual means for the development of neuro- 
muscular tone were employed. This case returned home at 
the end of two months in fair health and much relieved, but 
I have recently heard that she has relapsed. 
XIII.-The next case was that of a lady, aged 34, who 
had been confined to the bed and a wheel-chair for seventeen 
years. She stated soon after coming, December, 1884, that 
exactly seventeen years before she had gone to church for 
the last time and attended five services. Spinal pain and 
weakness had been prominent symptoms throughout the 
case, and had resulted in a readjustment of the reflexes to 
the abnormally restricted condition. That this patient was 
walking within a few days and improved steadily in all re- 
spects was largely due to her own intelligent and hearty co- 
operation, once the condition was explained to her. For 
some weeks her main difficulty was in accustoming the soles 
to bear the pressure of use, for the feet had lost their form 
and character, and required to be reshaped. She went home 
at the end of four months, walking freely and in fair health. 
A month after she reported in fine condition, having gained 
twenty-five pounds in four months and a half. While not 
robust she leads a tolerably active life, visiting, shopping, HYGIENE OF REFLEX ACTION 
and attending to her domestic and social duties at her pleas- 
ure. 
It is not necessary to prolong this enumeration of type- 
cases, where, from causes depending upon local conditions and 
upon states of the centres, the associated reflexes of the trunk 
and limbs, or of special areas, have become too keen, too 
sluggish, or too disorderly. The object of these outlines is 
to indicate that such detrimental conditions do exist in vari- 
ous localities, either alone or associated with organic or func- 
tional troubles, and that they are susceptible of analysis and 
rational treatment. Sometimes the consideration of faulty 
reflexes will not be important, in view of more urgent indica- 
tions, but there are cases of serious local or general disturb- 
ance where the best results have been obtained by progres- 
sive, systematic training and development of associated mus- 
cular movements. By thus feeding in appropriate stimuli, we 
can fill up gaps and reclaim barrens in the centres, balancing 
and distributing nerve-force as may be desired. The steps 
must often be so gradual as to commit the centres to a certain 
line of action, stimulate consciousness of power, and promote 
nutrition, without exciting the inhibition of undue fatigue, 
pain, apprehension, or resistance, but in certain cases very 
much may be accomplished by sudden and profound impres- 
sions. The training will often be directed to regions remote 
from the part affected; for instance, a functional spasm in the 
lower extremity may be favorably affected by the exercise of 
the trunk and arms as a physiological diversion. The effect 
of local treatment in exaggerating the attention already fixed 
upon the affected part should be carefully considered. 
We are frequently obliged to draw up a physiological bal- 
ance-sheet, and, if necessary, place the system in the hands of 
a receiver, going over the assets and liabilities, finding where 
the former can be increased and the latter diminished, where 
idle capital can be made to yield interest, and wasteful extrav- 
agance checked. These patients have the right to expect 
something more than the prescription of drugs, diet, braces, or 
exercise. Quantitative analysis of the various activities of 
the organism will he needed, and a complete system of physi- 
cal economies adopted, which shall recognize and regulate, so 
21 22 
HENRY LING TAYLOR. 
far as may be desirable, all the functions and all the condi- 
tions of life. Change of moral atmosphere, separation from 
the family, the acquisition of definite aims and purposes, the 
control of emotional excess, the introduction of order and 
system into daily habits, are examples of what is meant. 
Much of this will best be done indirectly by the modify- 
ing influence of neuro-muscular training on the organism and 
its higher centres. We wish to practise economy in the or- 
ganism, not that we may spend less, but more in the long 
run. Analysis should reveal weak points in order to 
strengthen them and make the organism more efficient. 
In concluding, I will mention some of the means which we 
have found useful in promoting reflex hygiene : Daily rest, 
lying down at a stated hour, with complete relaxation of mind 
and body. 
Systematic heating of the legs from above the knees by 
the hot-air box, kept at a temperature of about 130-1400 F. 
Drill in the " standing frame," with knees or hips, or both, 
supported, thus training the centres without the disturbing 
influence of balancing the body, and enabling the physician 
to throw more or fewer muscle-groups into active use while 
giving all the stimulus of standing. 
Drill in locomotion, free or between parallel bars. 
Localized active and passive movements by hand and by 
means of special apparatus, susceptible of accurate adjustment 
of the resistance and amount of motion, among the most use- 
ful of which for the purpose considered are : 
Passive alternate, right and left flexion of the trunk by 
means of steam-power apparatus, patient lying ; 46 complete 
movements a minute ; 2,760 an hour. 
Active flexion and extension of trunk through lumbar 
region, patient lying ; the upper or lower half of the body 
fixed as desired. 
Passive (steam-power) flexion and extension at the knees, 
patient seated. This apparatus gives 2 5 movements of flexion 
and extension a minute ; 1,500 an hour. 
Passive (steam-power) flexion and extension at hips and 
knees, patient partly reclining ; 23 complete movements a 
minute, or about 1,400 an hour. HYGIENE OF REFLEX ACTION. 
23 
Active extension at the hips and knees, patient partly re- 
clining ; and flexion and extension at ankle, both against grad- 
uated resistance. 
Weight and pulley for arm-movements. 
Artificial respiration by means of an apparatus known as 
the " respirator " (steam-power), which produces full inspira- 
tion and expiration, by drawing the arms of the patient 
strongly upward, the chest being at the same time arched 
back; the patient is reclining and passive, except as to 
grasping the handles of the apparatus. This machine has 
rendered us yeoman service in regulating reflexes and dis- 
tributing nerve-energy, besides which, it develops the chest, 
oxygenates the blood, equalizes the circulation-warming the 
extremities-and acts as a general tonic to the system. We 
use two apparatus, one giving 13 and the other 16 respirations 
a minute. 
The exercise-room is provided with couches, and all pa- 
tients are required to rest before and after each movement. 
What I wish to emphasize as the central idea of this paper 
is the development and use of associated reflexes as a practi- 
cal means of modifying nerve-centre function. The spinal 
and cerebral factors are to be recognized and differentiated, 
in order to send re-enforcing or inhibiting impressions into 
appropriate areas, by applying or removing particular stimuli, 
and thus to effect an advantageous redistribution of their 
energy.