ON THE UTILITY OF SUSPENSION IN DISEASE OF THE SPINAL CORD. ILLUSTRATED BY A CASE. BY DAVID D. STEWART, MD., DEMONSTRATOR OF DISEASES OF THE NERVOUS SYSTEM, AND CHIEF OF THE NEUROLOGICAL CLINIC IN THE JEFFERSON MEDICAL COLLEGE ; PHYSICIAN TO ST. MARY’S HOSPITAL, AND TO ST. CHRIS- TOPHER’S HOSPITAL FOR CHILDREN. pi FROM THE MEDICAL, NEWS, September 12, 1891. [Reprinted from The Medical News, September 12, 1891/L ON THE UTILITY OF SUSPENSION IN DISltAjHi OF THE SPINAL CORD; ILLUSTRATED BY A CASE. By DAVID D. STEWART, M.D., DEMONSTRATOR OF DISEASES OF THE NERVOUS SYSTEM, AND CHIEF OF THE NEUROLOGICAL CLINIC IN THE JEFFERSON MEDICAL COLLEGE ; PHYSICIAN TO ST. MARY’S HOSPITAL, AND to st. Christopher’s hospital for children. There is in medicine a certain class of ill-balanced enthusiasts akin to those that have been aptly styled by Bartholow, “quidnuncs,” on whose minds a suggestion of a novel therapeutic method is prone to make an impression like the desert’s mirage on the vision of a deluded wanderer astray—conceptions of possibilities impossible. The illogical expectations of this class have not only created illusive hopes in many a sufferer, but have often served to bring dis- credit and oblivion to measures that, divested of all fanciful expectations, have in them much of good. That this is true of more than one method of treat- ment, once the fad of the world medical, now only spoken of to be condemned, there is no doubt. More than two years have elapsed since the sus- pension-treatment of diseases of the spinal cord was introduced to the profession by Professor Charcot— a sufficient time in which to form a just estimate of its value. As a matter of course, so novel and promis- 2 STEWART, ing a therapeutic measure for a class of affections so little susceptible of amelioration by any treatment, fathered by so eminent a neurologist as Charcot, not only attracted general attention, but was received almost with enthusiasm everywhere. The lay press vied with the medical press in accounts of the method, and soon the journals teemed with reports of its trial, generally favorable at first, but subse- quently less and less so, until now it may be sup- posed that there are few who, if questioned as to its efficiency, would reply other than that it has had a fair trial and “ its day.” I publish this note for the purpose of entering protest against this notion, and to urge that a method that can be productive of so much good, even if only in a small percentage of cases, should not be abandoned unless another more efficient can be found to replace it. Suspension has fallen into discredit with many largely because too much was expected of it. I still maintain the opinion I ex- pressed two years ago, when perhaps the first to report a series of cases in which this treatment was tried: “That suspension will, even though aided by wisely directed medical and hygienic means, effect a cure in degenerative diseases of the cord is, I think, doubtful; but, as an adjunct to other modes of treatment, its utility is beyond question.” I made no extravagant claims for this measure then,1 nor do I now. The assumption that non-inflamma- 1 I shall not now revert to the cases first reported. A further account of these, together with a report of others under observa- tion subsequent to the date of my first paper, will be published at a future day. THE SUSPENSION TREATMENT. 3 tory affections due to an actual degeneration of nerve-elements could be vitally influenced by mechanical means, was not to be entertained ; but that the progress of the most common of those that, uninfluenced by treatment, are apt to show a progressive tendency, could not infrequently be arrested and a decided improvement accomplished— though arrest and improvement might be but tem- porary—more promptly by suspension than by any other therapeutic procedure, has been unquestion- ably shown. That it should be most efficient, and more than palliatively so, in chronic inflammatory and sub-inflammatory affections of the cord, in those in which the diseased process has had its origin in the intertubular tissue rather than in the nerve-ele- ments, its probable modus medendix indicates. Cases of ordinary chronic myelitis, of cord-sclerosis, the mode of onset, symptoms, and course of which place them in an intermediate position between inflammatory and degenerative affections, are those most likely to be permanently benefited by suspen- sion. A case of postero-lateral sclerosis, the clinical history of which indicates that it belongs to the latter class, has been under observation for several months, with improvement so gratifying that I shall report it here as an example of what suspension not infrequently accomplishes : E. R., aged thirty-eight, had been a railroad en- gineer from early manhood, until crippled by the spinal malady for the treatment of which he came. 1 Separation and breaking down of inflammatory adhesions ; relaxing compressed though still healthy nerve-tissue. 4 STEWART, He had been injured on the road a number of times about the head, body and limbs, but not for several years immediately preceding the onset of the exist- ing trouble. No apparent ill results followed the accidents, and he was in seemingly good health in the early part of 1890, when he first noticed that sensation in the soles of the feet was impaired. This impairment was gradual and progressive until it reached the upper part of the thighs. At about the same time, or a little earlier, his gait became unsteady, especially in the dark. He felt tired in the back and loins on exertion, and the legs were more or less stiff and unwieldy. There were occa- sional lightning pains in the thighs, but never of great severity. He had been under treatment in the medical clinic of the hospital of the Jefferson Medical College for several months without improvement and was transferred to the neurological department by Dr. Louis Brinton in November. It was then noted that his gait was highly ataxic, and of the sort best described as reeling—an ataxia not unlike that present in cerebellar disease. He was unable to stand or to walk with closed eyes. The lower limbs were quite rigid. The knee-jerk was much exag- gerated, but no rectus or ankle-clonus could be ex- cited. The plantar, cremasteric and lumbar reflexes were absent; the abdominal reflex was present; gluteal and scapular reflexes were present on the right side. There was decided plantar anesthesia, and partial tactile loss in the legs extended somewhat above the knees. There was partial anesthesia of the hands and fingers, with some loss of the muscu- lar sense. Pain-sense was everywhere preserved. The plantar temperature-sense was delayed and dulled, more decidedly to heat than to cold. The muscles were large, well-nourished, and without tenderness on pressure. There was always normal THE SUSPENSION TREATMENT. 5 faradic and galvanic response. The electrical ex- amination was repeated on several occasions. A dull, aching pain in the lumbar region, with a sense of constriction about the waist and abdomen, had been constant from the first. A hot sponge drawn along the spine gave rise to a burning sensation in this situation. There was some tenderness on pressure over the spinous processes of the lumbar vertebrae. There had been loss of sexual desire and ability to perform the sexual act for about a year. Hearing had been impaired for a number of years. It had improved about a year immediately preceding the onset of the spinal affection, but subsequently again became worse, being deranged in a manner some- what different from the primary impairment. The patient observed that whispers could be distinguished better than loud sounds, and low tones better than those of high pitch.1 The eye report by Dr. 20 20 Hansell was : R.—; L. pupils react to light XL XXX and accommodation; visual field normal; venous hyperemia of the right disc ; commencing atrophy of the left nerve. There was no history of syphilis. Treatment by suspension was begun on November 19, 1890, all in- ternal medication being discontinued. The condi- tion of the patient at that time was as narrated. From this date he was suspended three times weekly until 1 Dr. C. H. Burnett recently very kindly made an aural ex- amination. He reported: Left membrana tympani greatly thickened and retracted, lusterless and blue; right membrane similar, though lusterless in less marked degree. Chronic non-suppurative catarrh of both ears ; whispers near the ear are better distinguished than the loud voice, and low tones generally are distinguished more readily than high. High-pitched, loud sounds seem to cause an ataxia of appreciation of sound. 6 STEWART, about the middle of April, 1891. The suspensions were made as often by the head alone as with the arm and head-supports. When the axillary straps were also used he was always swung clear of the floor, and, after the fifth time, the duration was about five min- utes. Improvement began after the fourth suspension, and was continuous. It was most decided as regards the ataxia, the most prominent symptom. After the twelfth suspension he abandoned his stick alto- gether in walking. About the middle of April, less than five months after the treatment was begun, the ataxia had lessened so decidedly that the patient was able to take a position as switch-tender on the road. Since this date he has presented himself but once weekly for suspension. His gait is now no longer unsteady, unless he walks with his eyes closed or turns suddenly—then there is slight staggering. He is still unable to stand with his feet in juxtaposition and his eyes closed. The back pain and vertebral tenderness were early relieved by suspension and soon disappeared.1 A hot sponge, drawn along the spine, causes merely a sense of greater warmth in the lower lumbar region (where before burning was felt) than above. Tactile sensation in feet and legs is much improved. The temperature-sense is still imperfect and delayed. The plantar, abdominal, epigastric, gluteal and lumbar reflexes can now be elicited on both sides. The right knee-jerk is 1 The discomfort about the lumbar spine was nearly always lessened for a number of hours following suspension. I have noticed this in several cases. It is probably due to relief of the con- gestion and improvement of the circulation in the diseased area as a result of suspension. THE SUSPENSION TREATMENT. 7 slightly excessive, the left is normal. The legs are much more supple than they formerly were. There is slight ataxia in the right hand, but the patient is much less clumsy with the fingers. Sexual desire has returned; the power, only slightly. Hearing seems more acute than it was at first. When spoken to in a high-pitched voice the patient understands better than he did. The eye condition has not improved. The result of suspension in this case was so de- cided and so gratifying that I deemed it worthy of special report in connection with the few remarks preceding its narration. It exemplifies what sus- pension can do. Even if such results are obtained in but a minority of cases, is that sufficient reason for its entire abandonment ? 2620 N. FIFTH STREET. THE MEDICAL NEWS. A National Weekly Medical Periodical, containing 24-28 Double- Columned Quarto Pages of Reading Matter in Each Issue. $4.00 per annum, post-paid. That The News fulfils the wants of men in active practice is made clear by the steady growth of its subscription list. This increase of readers has rendered possible a reduction in the price of The News to $4.00 per year, so that it is now by far the cheapest as well as the best large weekly journal published in America. Every mode of conveying serviceable information is utilized. 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