The History of Modern Spinal Traction with Particular Reference to Neural Disorders

The history of modern spinal traction with particular reference to neural disorders

Michael V Shterenshis The Hebrew University ± Hadassah Medical School, Jerusalem, Israel

The last 200 years of the history of spinal traction is described in the present article. The study starts at the end of the 18th century with the works of JA Venel (1789) who tried to apply the Hippocratic idea to modern surgery. Orthopedic specialists of the last century were mostly preoccupied with corsets and the method gained broader popularity when neurologists paid attention to the similar method of suspension. The Russian neurologist Osip Mochutkovsky described suspension as a method for the treatment of tabes dorsalis in an article published in the Russian magazine `Vratch' in 1883. His works became known in Europe when JM Charcot paid attention to it and published a special short monograph on this subject in 1889. This work was translated into English (1889) and Russian (1890) and the method became popular in the treatment of tabes dorsalis and other neurological diseases. The eminent Russian neurologist VM Bekhterev proposed the combination of body suspension with cervical traction (1893). Some years later Gilles de la Tourette promoted the use of spinal traction in his neurological clinic (1897). Unfortunately neurologists worked without the cooperation of orthopedic specialists. During the ®rst decades of the 20th century suspension was also replaced by traction in neurology. This method was used by both neurologists and orthopedic specialists but in the last decades neurologists lost their interests in it and it found greater use in traumatology and in spinal surgery where it is still in use today.

Keywords: spinal fraction; neurological disorders; orthopedic equipment; history of medicine

Introduction Both spinal and skeletal traction methods have a long external view of the device was closer to the naive history. The development of skeletal traction has been devices of the previous century. Venel considered his described in some detail1,2 while the history of spinal bed as èxclusively' his own method.4 The next step traction gained less attention. The idea was known towards modernization was made by other physicians. from the time of Hippocrates and Galen but it only In 1810 the German physician D Schreger oered the became fully implemented in modern times. In this modern looking spinal traction bed.5 The device had a study the history of modern spinal traction will only be waist-belt and a head halter. The pelvic end was ®xed considered for the last 200 years. and the spinae distorsio was performed by neck Since Antiquity individual enthusiastic medical men traction (Figure 1). including Glisson in the 17th century and Erasmus Orthopedics was not yet an independent medical Darwin at the end of the 18th among several other discipline. Contemporary surgeons preferred to treat physicians were trying to apply traction for certain spinal diseases, traumas and even dislocations by spinal disorders. Lack of adequate technical means corsets. These corsets, in the beginning, were rather and of correct anatomical knowledge led to unsuccess- crude. A typical `machine for supporting the head and ful results and gave birth to a popular saying that shoulders' of that time consisted of àn iron collar, `hunchback will only be cured by the grave'. But the properly covered, for passing round the neck' and à idea survived over two millennia and by the end of the broad iron plate, ®tted to the back and shoulders'.6 18th century it had proved to be useful. In 1789 Jean- It does not mean, of course, that the method was AndreÂ Venel (1740 ± 1791) of Switzerland introduced totally forgotten since the time of Hippocrates' lit aÁ extension, the extension bed for scoliosis scamnium. Even Glisson's halter was introduced in treatment by traction and countertraction in the the 1600s. Glisson used spinal traction in the 17th horizontal position.3 Venel used a tight cap with a century to correct spinal deformity, and of course was hook and armpit loops, all ®xed to the head of the by no means the ®rst to attempt this. In fact, from the bed, for traction and a pelvic girdle with straps, ®xed beginning of the 19th century spinal traction had been to the lower end of the bed, for countertraction. The an integral part of the surgical armamentarium for the The history of modern spinal traction MV Shterenshis 140

treatment of deformity. But during all of that time this the same bed (Figure 2). Schreger counted his device as useful method was not enforced with proper mechan- a short-term procedure, but Frenchman Maisonabe ical devices. Furthermore, the inventors of new oered it for long-term purposes. At the same year two machines often made no references to the previous other French surgeons Lafond and Duval invented ones. Thus, M Andry in France treated rickets by both traction bed and traction chair with weights. suspension using a bandage across the chest, under the Their apparatus were described also in English in axillae and crossed under the chin (1743). This was a London Medical and Physical Journal for December replica of Glisson's sling of the 17th century but 1826.9 At the same time the English physician D Shaw Andry did not mention Glisson.7 Venel also pointed designed a traction bed with sliding frame and out that his method `is exclusively my own and the weights.10 basis of my particular treatment'.8 D Schreger also The main indications for spinal traction at the produced his traction bed without any reference to beginning of the 19th century were scoliosis, backache previously used machines. of dierent origins and locations, rickets and spinal deformities.11 The new generation of inventors also tried to make the procedure less painful and more The traction bed comfortable. Maisonabe even presented a picture Schreger's invention did not attract immediate medical (Figure 2) showing a woman quietly reading a book attention. But in 1825 CA Maisonabe designed nearly during the procedure.

Figure 1 The spinal traction device of DBG Schreger. From Schreger DBG, 1810

Figure 2 The French spinal traction device of CA Maisonabe. From Maisonabe CA, 1825 The history of modern spinal traction MV Shterenshis 141

Approximately at the same time (1828) JM Delpech gical means, physicians investigated other possible in France applied head traction and pelvic counter- methods of treatment ± electrotherapy, hydrotherapy, traction for the patient while supine in his treatment physical therapy, even acupuncture. In this context for scoliosis12 and Ch-G Pravaz designed a bed with was neurological spinal traction invented. progressive extension (1827).13 Actually, the history of neurological spinal traction All these English, German and French devices are begins with body suspension. In 1883 the leading surprisingly modern-looking. They are even more Russian medical journal Vratch (`The Physician') complicated than those of the 20th century. But the published the long article of Osip Mochutkovsky method did not become popular. The contemporary entitled: `Application of the patient's suspension to Dictionary of Practical Surgery14 did not even mention the treatment of several spinal disorders'. O Mochut- it. Despite the eorts of some individual surgeons the kovsky was a gifted medical inventor. For example, he corsets were still the main mechanical device for spinal created a `tactsiometer' ± a special device to test column care. sensation. In 1883 he worked as a physician in the neurological division of the Odessa City Hospital, and in 1893 became professor of neurology in St Traction corsets Peterburg. The idea to combine corset with traction treatment Mochutkovsky used Sayre's corset for suspension goes back to the 18th century, to the appliances of F-G below the arm-pits with a collar-like neck ®xation.21 Levacher, who devised a spinal corset incorporating He tried to cure 23 patients with this method, 15 of head traction (1764) and similar looking `daytime them had Tabes dorsalis (locomotor ataxia). Others appliance' for spinal curvature of Venel (1789).15 had lateral sclerosis, ischias (sciatica) and chronic In the 19th century A Bonnet in France tried to myelitis. He succeeded in obtaining a body elongation obtain some traction by using a corset. In 1845 he was of up to 5 cm and vertebral elongation of up to able to achieve some success in treating a curved 2.5 cm. The most vivid results were achieved by spinal column by using a slowly elongated corset with Mochutkovsky for patients with tabes; there was a neck collar, but only in the case of a young child.16 decrease of pain, an improvement in walking, and In general, orthopedic corsets of the 19th century even reduction of the intensity of Romberg's sign.22 were of little value. `Spinal supports of all kinds ± He observed no signi®cant side-eects and proposed corsets, mechanical appliances, particularly the `spinal suspension for the cure of tabes dorsalis. The assistant' of Charles Fayette Taylor ± were pure syphilitic origin of that disease was still doubtful in `make-believe', because they did not and could not 1883, tabes was incurable and Mochutkovsky relieve the spinal column of its weight-bearing proposed suspension as a successful palliative function'.17 method. Nevertheless, the corsets were constantly improved. This article did not attract much attention in In the last quarter of the 19th century the most Russia. Mochutkovsky was then using suspension in popular of them was the one devised by the New York the Odessa City Hospital alone. Happily it happened orthopedist LA Sayre (1820 ± 1900). Sayre's corset, a that in October 1883 F Raymond, pupil and future plaster jacket, was in fact applied under suspension. successor of JM Charcot, visited Odessa on his trip But Sayre himself used suspension not for treatment through Russian neurological clinics. Mochutkovsky but only to prevent folds on a closely-®tting under- demonstrated to him his method and Raymond was shirt.18 The method was also well known in America impressed. Upon returning to Paris Raymond and in Europe because Sayre's book on the subject informed Charcot about the suspension technique. was published in the USA and in Great Britain at the Charcot was quick to test out the new method. same time.19 Already in January 1889 he ocially approved it and Sayre tried to treat Pott's disease, with good results, 1-month later reported about 40 patients with Tabes and scoliosis with less impressive results.20 The weak dorsalis cured by suspension.23 His work was point of his book was that he did not mention his immediately translated into English.24 One year later predecessors. Charcot reported about 100 patients treated with suspension with good results. This work was also translated into Russian25 and thus Mochutkovsky's Body suspension method achieved adequate feedback and became But there was a procedure with ability to `relieve the known in his own country. spinal column of its weight-bearing function'. This Charcot and his pupil Gilles de la Tourette procedure was body suspension and this method improved the neck collar and made it look more like entered medicine through the gates of neurology. the modern head halter cervical traction device (Figure In the second half of the 19th century, neurology, 3). Like most contemporary clinicians, Charcot had then a newborn independent clinical discipline, was little regard for pharmacological therapies, he was facing therapeutic nihilism. Materia medica was therefore trying to ®nd other methods of treatment. useless for more than a half of nervous diseases. He tried hypnosis for hysteria and almost failed, he Trying to con®ne therapeutic nihilism to pharmacolo- invented a special helmet to treat migraine and totally The history of modern spinal traction MV Shterenshis 142

failed, he proposed the vibration armchair for and A von Strumpell (Germany) had a negative Parkinson's disease and failed again. But suspension opinion as several articles28 described patient's death was successful and Charcot started to use it very in the neck halter's loop during self-suspension at widely. One of his patients had the suspension home. The German professor E von Leyden (1832 ± procedure performed every day for 3 years, more 1910) prohibited the method in his Berlin clinic. The than 1000 times.26 American Neurological Society's reaction was also Both Charcot and Mochutkovsky believed that the negative.29 Critics said that this method was non- success of the treatment was a result of slight physiological and caused local spinal hyperemia. extension of nerve roots and the improvement of Something then had to be done in order to improve spinal blood circulation. Neither Sayre or Mochut- the method and the eminent Russian neurologist VM kovsky mentioned the works of orthopedists. There- Bekhterev proposed the combination of suspension fore Charcot cited only Sayre and Mochutkovsky. with traction. In his main article on that theme, After 1890 a wide discussion began on the published in 1893,30 he described the improved neck method.27 Several professors such as JM Charcot halter and suspension from the elbows of the seated and G Gilles de la Tourette in France, W Erb and A patient (Figure 4). He started to use weights. Basically Eulenburg in Germany, M Benedict in Austria, VM he used cervical traction with some body suspension. Bekhterev in Russia, J Althaus in Britain greatly From a modern point of view this method was not favoured suspension. However, W Gowers (Britain) very comfortable but it was a step forward. Another of Bekhterev's innovations was an application of the method for other spinal problems. Degenerative disc disease was unknown at that time, but Bekhterev found suspension to be useful for the treatment of lumbago and sciatica. His pupil BI Voroteensky

Figure 3 The Mochutkovsky ± Charcot suspension techni- Figure 4 Bekhterev's technique of suspension with cervical que. From Charcot JM, 1890 traction. From Bekhterev VM, 1893 The history of modern spinal traction MV Shterenshis 143 investigated the usefulness of suspension for lower As for suspension the manual was correct, but back pain and neck pain of dierent origins.31 In 1895 spinal traction was proceeding. Two main problems he proposed horizontal spinal traction for the were then prevalent: to choose the correct indications treatment of compression myelitis.32 and to ®nd a reasonably safe technique for the procedure. The main indication, tabes dorsalis, was out of the question for two reasons. The ®rst was Suspension vis a vis traction undoubtedly the fact that a new pharmacological At last in 1897 Gilles de la Tourette created his own treatment for syphilis (Salvarsan, etc) was developed spinal traction device for sitting patients with several and all other palliative means were abandoned. The belts and weights (Figure 5). The patient was bent second was that tabes became very rare in the middle forwards and a gravity method of suspension changed of our century. The indications shifted to the to traction with carefully gauged weights. The numerous syndromes involving neck and low back suspension method then became obsolete and spinal pains and to sciatica, as neurologists still maintained traction spread widely in neurological clinics. that the cure of back pain was under their own sole It did not mean, of course, that suspension responsibility. treatment immediately disappeared. In France it was It is a strange fact that neurologists such as Charcot in use even in the 1920s. The Larousse MeÂ dical or Gilles de la Tourette, inventing their own above dictionary even included a picture of self-suspension. mentioned devices, never wrote about the same use by The indications were tabes, Parkinson's disease, orthopedists. neurasthenia with vertigo, and impotence.33 Americans were still rather reticent toward the method. `Suspension was recommended by Mochut- Skeletal traction kovsky in 1883. In the decade following, neurologists Neurologists, of course, did not take up skeletal of every nationality testi®ed to its ecacy in traction, as the main indications for this method are ameliorating the symptoms of tabes and apparently for dierent fractures of the bones. In fact the history in modifying the course of the disease. During the past of modern skeletal traction starts at the end of the 19th few years very little had been heard of it, and its use century when aseptic and antiseptic measures were has been generally discontinued', ± a reported serious introduced to medicine. Since that time the use of rods American therapeutic manual in 1926.34 and screw hooks became possible without infectious

Figure 5 The spinal traction technique of Gilles de la Tourette. From Gilles de la Tourette G, 1898 The history of modern spinal traction MV Shterenshis 144

complications. At this same time, orthopedic specialists scoliosis is known today as Kinder-Harrington tried to improve the spinal traction. rodding.37 Moreover, halo-femoral traction is used The safety of the procedure was the second important for spinal deformities with neurological complica- problem for neurologists, neurosurgeons and orthope- tions.38 dists. The chin-head halter traction was the weakest The method is also used in traumatology (eg from point of the method. The skin can hardly tolerate car accidents), and in manual medicine there is the traction of more than 2.5 to 3 kg (5 to 6 lbs appr.) for a method of spinal non-skeletal autotraction.39 long period of time because of the danger of skin However, spinal traction now seems to be lost for necrosis of the chin and occipital regions. When neurology. `Many of us recall the days when patient Glisson's Head Halter was introduced into practice the after patient would be admitted to hospital for problem was not yet solved. The torques of Antonius traction. Fortunately, the cost of such treatment and Nuck (1696) and Erasmus Darwin's `neck swing' (1796) the lack of scienti®c basis have largely put an end to along with devices of M Langenbeck (1850) and Charcot such a useless endeavor', ± this is a quotation from (1890) are just a few attempts to improve the head halter Backache second edition in 1990.40 `Pelvic traction but the problem still remained. Due to constant generally has not been found eective except to help improvement of the device traction became extremely enforce strict bed rest', ± echoes the Manual of popular in the middle of our century. An Atlas of Neurology in 1992.41 These two quotations sound Orthopedic Traction Procedures dated 1954 shows like a verdict against the use of spinal traction in the numerous traction devices indications and positions.35 neurological clinic. Russia is perhaps nowadays the Most chapters are dedicated to skeletal traction with a only country where spinal traction is still used in a screw hook. These surgical procedures are somewhat neurological context. Thus a modern Russian neuro- removed from neurological spinal traction. Skeletal logical textbook advises `traction therapy on a sliding traction, therefore, has its own history, especially frame by using the body weight of the patient (timid concerning the techniques. suspension ± MV Sh.), traction in bed with non- Pre-operative spinal traction was used widely in speci®c devices, traction in water with weights Europe from the 1920s, although much less so in (another kind of timid suspension) and traction with America. technical devices' in case of backache.42 Spinal traction is still useful for surgery of the spine. In surgery and traumatology, however, skeletal In the 1970s traction using Glisson's head halter and traction became a part of cervical traction proce- pelvic straps of a pelvic girdle and continuous traction dures. After the development of antiseptic and later in bed with a sliding frame (semi-traction ± semi- aseptic measures, the development of local anesthesia suspension ± MV Sh.) were prescribed in the pre- became the second important step in this direction. operative stage (Figure 6).36 The method has been When preventive measures against infection and pain rarely used since the introduction of modern surgical complications had been secured, skeletal traction spinal instrumentation. The method of skeletal became the best method of cervical traction for use traction applied to the spine for the treatment of over prolonged periods of time.

Figure 6 Continuous traction in bed technique with Glisson's Head Halter and traction bed with sliding frame. From Rathke FW, Schlegel K-F, 1979 The history of modern spinal traction MV Shterenshis 145

It was mentioned above that the main complica- References tions of halter cervical traction were pressure sores under the chin and behind the occiput especially when 1 Bick EM. History and Source Book of Orthopaedic Surgery. The applied for long periods or when used with heavy Hospital for Joint Diseases: New York, 1933, pp. 7, 32, 42, 132, 43 133, 144, 145. weights. Skeletal traction was free from such 2 Rang M. Anthology of Orthopaedics. E & S Livingstone Ltd: complications. Edinburgh & London, 1966, pp. 160 ± 167. The third step in the history of skeletal traction 3 Le Vay D. The History of Orthopaedics. The Parthenon Publ. was an improvement of the instrumentarium. In 1933 Group: Carnforth, Lancs & Park Ridge, New Jersey, 1990, pp. 299, 533. Neubeiser ®sh hooks for zygomatic traction, and 4 Ibidem, p. 533. Crutch®eld tongs were introduced simultaneously. 5 Schreger DBG. 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